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MD3002 > Physiology of GI Disorders > Flashcards

Physiology of GI Disorders Flashcards

1
Q

Give examples of complex neurodisabilities.

A

Cerebral palsy

Autism

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2
Q

Identify potential GIT problems that patients with complex neurodisability may have.

A

Sialorrhea (excessive drooling)

Dysphagia (difficulty swallowing), associated with weight loss, and pneumonia (if aspirate fluids and food)

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3
Q

Identify potential managements for sialorrhea in patients with complex neurodisabilities.

A
  • Anticholinergic medication
  • Transdermal scopolamine patches (Scopoderm TTS)
  • Ultrasonography-guided Botulinum Toxin type A injections into bilateral parotid and submandibular glands
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4
Q

Identify some of the side effects of anticholinergic medication, which is sometimes used to manage silorrhea in patients with complex neurodisability.

A

Side effects of anticholinergic medication:

  • Drowsiness or sedation
  • Blurred vision
  • Dizziness
  • Urinary retention
  • Confusion or delirium
  • Hallucinations
  • Dry mouth
  • Constipation
  • Reduced sweating and elevated body temperature
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5
Q

Explain the technique of transdermal scopolamine patches to manage sialorrhea in patients with complex neurodisabilities.

A

Application of a skin patch behind the ear, at the level of the mastoid process

Patch releases a sustained dose of 0.5 mg of scopolamine per day and must be changed every 72 hours, alternating between the right and left sides at each change.

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6
Q

Identify management techniques for dysphagia/weight loss in patients with complex neurodisabilities.

A
  • Feed nasogastrically (not sustainable in the long term)

- Gastrostomy (tube into GI tract, can use button to take away need for tubing to make it more comfortable)

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7
Q

Define coeliac disease.

A 
Autoimmune condition. 
Small intestine (the part of the intestine where food is absorbed) becomes inflamed if they eat food containing gluten. This reaction to gluten makes it difficult for them to digest food and nutrients. Gluten is found in foods that contain wheat, barley and rye (such as bread, pasta, cakes and some breakfast cereals).
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8
Q

Which of males or females are more affected by Coelic disease ?

A

Females are more affected

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9
Q

What are the symptoms of coeliac disease ?

A

Symptoms of coeliac disease may be similar to those of other conditions such as irritable bowel syndrome. Common symptoms include:

  • indigestion
  • constipation
  • diarrhoea
  • bloating
  • stomach pain.

People can also develop

  • anaemia (a condition in which a person doesn’t have enough red cells in their blood to carry oxygen around the body)
  • lose weight
  • ongoing tiredness
  • weak bones
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10
Q

How many coeliac disease be diagnosed ?

A

1) Serology testing (antibodies are produced in response to gluten):

  • Request total immunoglobulin A (IgA) and IgA tissue transglutaminase (IgA tTG) for serological testing
  • A positive serological result is an unequivocally raised IgA tTG.
  • If IgA tTG is weakly positive or total IgA is deficient (usually defined as less than 0.07 mg/L) the laboratory should automatically carry out supplementary tests.

2) Refer all patients with positive serology and those with negative serology in whom coeliac disease is clinically suspected to specialist gastroenterological services:
• A positive serological test is not diagnostic of coeliac disease (serological tests can give false positive results) and a duodenal biopsy should be used for definitive diagnosis.

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11
Q

Describe management of coeliac disease.

A

-Lifelong gluten-free diet

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12
Q

What proportion of coeliac disease patients are undiagnosed ?

A

4/5 are undiagnosed

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13
Q

Which patients should we test for coeliac disease ?

A

Patients with these symptoms or conditions:
• Persistent unexplained abdominal and gastrointestinal symptoms
• Faltering growth
• Prolonged fatigue
• Unexpected weight loss
• Severe or persistent mouth ulcers
• Unexplained iron, vitamin B12, or folate deficiency
• Type 1 Diabetes (at diagnosis)
• Symptoms of irritable bowel syndrome (abdominal pain, bloating, and/or altered bowel habit) in adults
• Autoimmune thyroid disease
• First degree relatives (parents, siblings, or children) of people with coeliac disease

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14
Q

Which patients should we CONSIDER testing for coeliac disease ?

A

Patients with these symptoms or conditions:
• Metabolic bone disorder (reduced bone mineral density or osteomalacia)
• Unexplained neurological symptoms (particularly peripheral neuropathy/ataxia)
• Unexplained subfertility or recurrent miscarriage
• Persistently raised liver enzymes with unknown cause
• Dental enamel defects
• Down’s syndrome
• Turner syndrome

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15
Q

Is a combination of positive serology and symptom relief following gluten exclusion diagnostic of coeliac disease ? Why or why not ?

A

No, because presenting symptoms might be related to another disorder responding to gluten withdrawal eg irritable bowel syndrome.

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16
Q

What is the main issue with diagnosing coeliac disease based only on a positive blood test result ?

A

Diagnosing coeliac disease based only on a positive blood test result may lead to the patient starting a strict lifelong gluten free diet without having the disease.
The resulting absence of gluten in the diet will make it difficult to confirm a
diagnosis if there is any doubt at a later stage.

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17
Q

Identify possible complications of coeliac disease.

A
  • Malignancy, especially lymphoma

- Osteoporosis

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18
Q

Identify the main tasks in the annual review of a patient with Coeliac Disease.

A
  • Measure weight and height; calculate BMI
  • Review symptoms
  • Consider the need for assessment of diet and adherence to the gluten free diet
  • Consider the need for specialist dietetic review and nutritional advice
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19
Q

Identify foods not to eat in a gluten-free diet.

A

Any foods that contain:
• Wheat (and similar grains including spelt, couscous, semolina, and bulgar wheat).
• Barley.
• Rye.
• Many common foods contain gluten, including bread, cakes, biscuits, pizzas, cereals, and beers and ales.
• Many ready meals, soups, sauces, and sausages also contain wheat flour.

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20
Q

Identify a few examples of foods that are naturally free of gluten.

A
  • Rice,
  • Potatoes
  • Quinoa
  • Eggs
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21
Q

Are oats gluten free, or not ? Therefore, do coeliac disease patients react to it ?

A
  • Oats do not contain gluten but they do contain the protein avenin which is similar to gluten.
  • Some people with coeliac disease can react to avenin in the same way they would react to gluten.
  • Oats are often processed in the same environment as gluten containing products (wheat, barley, and rye) and are easily cross contaminated.
  • People with coeliac disease should therefore only eat oats certified as being gluten free
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22
Q

Identify any other diseases linked with coeliac disease. Does every patient with coeliac disease have this ?

A 
Dermatitis Herpetiformis (DH) 
No, DH affects fewer people than typical coeliac disease
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23
Q

Identify GI disorders.

A
  • Coeliac disease
  • GI issues related to complex neurodisabilities (dysphagia, sialorrhea)
  • Chronic constipation (in part due to lack of potty training)
  • Persistant vomiting in the newborn
  • Intestinal malrotation
  • Hypertrophic Pyloric Stenosis (HPS)
  • Small bowel obstruction
  • Large bowel obstruction
  • Paralytic Ileus
  • Acute pancreatitis
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24
Q

Which age ranges does coeliac disease affect ? What about Dermatitis Herpetiformis ?

A

Coeliac: mainly children, adults possibly
DH: DH can appear at any age, but is most commonly diagnosed in those aged between 50 and 69 years.

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25
Q

Identify the main symptoms of Dermatitis Herpetiformis.

A
  • Red, raised patches, often with blisters that burst with scratching
  • Severe itching and often stinging
  • The rash is most commonly seen on the elbows, knees and buttocks, but any area of the skin can be affected. The rash usually occurs symmetrically on the body, for example on both elbows
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26
Q

Describe diagnosis and management of Dermatitis Herpetiformis.

A
  • Diagnosis of DH is confirmed by a skin biopsy.
  • The treatment for DH is a lifelong gluten-free diet. As it can take a long time for a gluten-free diet to take effect, drug treatment is used to help control the rash to begin with. The most common drug prescribed for DH is Dapsone.
27
Q

Explain the importance of potty training.

A

Bad potty training of lack of potty training can lead to chronic constipation, behavior problems about toiletting. Child keeping it in, large intestine absorbing fluids, leading to constipation, which causes anal tears.
Next time because of that, child keeping it in for even longer.

28
Q

What substances do newborns vomit after birth ? How long does this vomiting usually last ? What are the main reasons newborns vomit after birth ?

A
  • Infants may vomit mucus, occasionally blood- streaked, in the first few hours after birth.
  • This vomiting rarely persists after the first few feedings; it may be due to irritation of the gastric mucosa by material swallowed during delivery.
  • In the majority of instances, it is simply regurgitation from overfeeding or from failure to permit the infant to eructate swallowed air.
29
Q

If neonatal vomiting persists, what are potential causes ?

A
  • When vomiting occurs shortly after birth and is persistent, the possibilities of intestinal obstruction and increased intracranial pressure must be considered.
  • A history of maternal polyhydramnios suggests upper gastrointestinal (esophageal, duodenal, ileal) atresia.
30
Q

What would bile-stained emesis from a newborn suggest ? How would this diagnosis be confirmed ?

A

Bile-stained emesis suggests intestinal obstruction beyond the duodenum and requires investigation (i.e. abdominal film)

31
Q

What features of an abdominal film would show duodenal atresia in a neonate ?

A
  • Characteristic “double- bubble” sign that confirms the diagnosis of duodenal atresia.
  • Dilated stomach and dilated proximal duodenum
32
Q

Describe normal rotation of the gut.

A
  • In the normal embryo, physiologic herniation of the gut through the umbilicus at 6 weeks is accompanied by a 270° counterclockwise rotation of the developing intestine around the superior mesenteric artery.
  • By 10-12 weeks, the intestine returns to the abdomen and assumes its normal adult anatomic position.
  • Normal small bowel mesentery has a broad attachment stretching diagonally from the duodenojejunal junction (in the left upper quadrant) to the caecum (in the right lower quadrant).
33
Q

Identify the ways in which malrotation can result in intestinal obstruction.

A
  1. Obstruction of the duodenum may result from congenital peritoneal bands (Ladds bands) which run over the duodenum from the caecum in the right upper quadrant.
  2. Normal embryologic sequence of bowel development and fixation is interrupted.
    Malrotated bowel is prone to torsion, resulting in midgut volvulus (i.e. loop of intestine twists around itself and the mesentery that supports it, resulting in a bowel obstruction)
  3. Internal hernia in the mesentry.
34
Q

Define Hypertrophic Pyloric Stenosis (HPS). Describe the epidemiology of it.

A

“Functional gastric outlet obstruction as a result of hypertrophy”, resulting in projectile vomiting.

It is more likely to affect full-term, first-born male infants and affects female infants less frequently. Also more common in Caucasian infants, and in infants with family history of the condition.

35
Q

When does the vomiting of hypertrophic pyloric stenosis begin ?

A

The vomiting of pyloric stenosis may begin any time after birth but does not assume its characteristic pattern before the 2nd-3rd wk.

36
Q

Describe the treatment for hypertrophic pyloric stenosis.

A

Pyloromyotomy (“incision of the longitudinal and circular muscles of the pylorus”)

37
Q

Identify causes of neonatal vomiting, besides obstructions of the digestive tract.

A
  • Cows milk protein allergy,
  • Galactosaemia,
  • Increased intracranial pressure,
  • Septicaemia,
  • Meningitis,
  • Urinary tract infections.
38
Q

Describe the folds present in the small intestine.

A
  • The valvulae conniventes, also known as Kerckring folds, plicae circulares or just small bowel folds, are the mucosal folds of the small intestine.
  • Starting from the second part of the duodenum, they are large and thick at the jejunum and considerably decrease in size distally in the ileum to disappear entirely in the distal ileal bowel loops.
39
Q

True or false: The valvulae connivente (aka Kerckring folds) result in a classical appearance on abdominal radiographs, barium studies and CT scans.

A

True

40
Q

How much do small intestinal obstruction and large intestinal obstructions respectively account for all mechanical intestinal
obstruction ?

A

Small bowel obstruction accounts for 80% of all mechanical intestinal obstruction with the remaining 20% result from large bowel obstruction.

41
Q

Identify main categories of acquired causes of small intestinal obstruction.

A

Acquired causes may be extrinsic causing compression, intrinsic or luminal.

42
Q

What is the main cause of small intestine obstruction ?

A

In developed countries, adhesions are by far the most common cause, while in developing countries incarcerated hernias are much more common.

43
Q

True or False: Small bowel obstruction is one of the more frequent causes for surgical admission.

A

True

44
Q

How long is the large intestine ? Where does it start, and end ?

A

1.5 m

Large intestine extends from the caecum to the rectum.

45
Q

Describe the main macroscopic features of the large intestine.

A

Large intestine has three outer longitudinal muscular layers called taenia coli, which are about 30 cm shorter than the length of the large bowel causing characteristic sacculations interrupted by incomplete rings called haustra.

46
Q

Identify the most common causes of large bowel obstruction.

A

Age dependant.

1) In adults:
- Most common cause is colonic cancer, typically in the sigmoid colon
- Second most common cause in adults is acute diverticulitis (involving the sigmoid colon).
- Adhesions do not tend to cause large bowel obstruction.

2) In neonates
- Most common cause is Hirschsprung disease (short segment of colonic aganglionosis affecting term neonates, especially boys.)

47
Q

True or false: Hirschsprung disease is almost never seen in premature infants.

A

True

48
Q

What is the usual presenting complaint for a neonate with Hirschsprung disease ? What exactly is the time frame of this presentation ?

A

Term neonates with failure to pass meconium in the first 1-2 days after birth, although later presentation is also common.

~75% of cases present within six weeks of birth, and over 90% of cases present within the first five years of life. A very small number may present in the adult population.

49
Q

How is Hirschsprung disease definitively diagnosed ?

A

A definitive diagnosis requires a full thickness rectal biopsy.

50
Q

How is Hirschsprung disease treated ?

A

Surgical treatment is by removal of the affected portion of the colon (good prognosis if successful)

51
Q

What are potential complications of Hirschsprung disease.

A

Colonic perforation complicates the presentation and this and its sequelae significantly increase both mortality and morbidity.
Enterocolitis other possible complication

52
Q

True or false: Hischsprung disease can be associated with Down’s Syndrome.

A

True

53
Q

Define Paralytic Ileus. What is the cause of this ?

A

Functional intestinal obstruction without an actual physical obstruction.

Caused by a multifactorial malfunction in the nerves in the intestine and subsequent impairment in intestinal peristalsis (other factors involved are bowel inflammation and neurohormonal peptides)

Common causes: 
P: postoperative
P: peritonitis
P: potassium: low
P: pelvic and spinal fractures
P: parturition
54
Q

Identify the main clinical findings of Paralytic Ileus (symptoms, findings upon auscultation, findings in imaging).

A

Symptoms: similar to a mechanical bowel obstruction such as nausea/vomiting, distension, and reduced or absent bowel movements.

2) Auscultation: bowel sounds will be decreased / absent whereas they are increased in mechanical obstruction.
3) Imaging: Generalised, uniform, gaseous distension of the large and small bowel is evident on radiographs.

55
Q

Identify the main differences between mechanical and functional (i.e. paralytic ileus) obstructions.

A

On auscultation, bowel sounds will be decreased / absent in functional obstruction whereas they are increased in mechanical obstruction.

Involvement of small and large bowel and lack of a transition point on plain radiographs in functional obstruction, unlike mechanical small bowel obstruction.

56
Q

Define acute pancreatitis. How common is it and how has its incidence progressed over the past two decades ?

A

Acute pancreatitis is inflammation of the pancreas triggered by release of activated exocrine enzymes into the substance of the organ.

It is relatively common and has shown a 10 fold increase in many Western countries in the last two decades (but annual incidence varies in different parts of the world)

57
Q

What populations does acute pancreatitis affect ?

A

Rare in children, mostly adults

58
Q

Identify the main causes of acute pancreatitis.

A

BAD HITS

  • Biliary
  • Alcohol
  • Drugs (corticosteroids, HIV drugs, diuretics)
  • Hypertriglyceridemia/Hypercalcemia
  • Idiopathic
  • Trauma
  • Scorpion sting

Alcohol abuse and gallstone migration are the most common causes

59
Q

Is there any differences between men and women as to the causes of acute pancreatitis ?

A

Gallstone migrations as a cause of acute pancreatitis are more common in women than in men.

60
Q

Identify the main signs and symptoms of acute pancreatitis.

A

Abdominal pain that radiates to your back.
Abdominal pain that feels worse after eating.
Fever
Nausea
Cullen’s sign
Grey Turner’s sign

61
Q

Define Cullen’s sign.

A

Periumbilical ecchymosis (AKA Cullen’s Sign), results from tracking of blood from the retroperitoneum to the umbilicus along the gastrohepatic and falciform ligament and then subsequently to subcutaneous umbilical tissues through the connective tissue covering of the round ligament.

May occur in acute pancreatitis, as a result of liberated pancreatic enzymes causing the diffusion of fat necrosis and inflammation with retroperitoneal or intra abdominal bleeding..

62
Q

Define Grey Turner’s sign.

A

Grey Turner’s sign is produced by haemorrhagic fluid spreading from the posterior pararenal space to the lateral edge of the quadratus lumborum muscle and thereafter to the subcutaneous tissues by means of a defect in the fascia of the flank.

These signs, although not specific, may be associated with severe acute pancreatitis and a high mortality.

63
Q

How severe is acute pancreatitis ?

A

Acute pancreatitis may vary from mild (around 80% of cases) with recovery within a few days to severe (20%) acute pancreatitis with the need of prolonged hospital stay and critical care support.

64
Q

What is the mortality rate of severe acute pancreatitis ?

A

Severe acute pancreatitis is associated with a 15-20% mortality.

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