Primary care - GI & Renal Flashcards
What is diverticulosis?
What is diverticular disease?
What is diverticulitis?
Where in the colon is diverticular disease most common?
DIVERTICULOSIS is just the presence of diverticulae (sac like protrusions of mucosa through muscular wall of colon, usually multiple, 5-10mm in diameter) (normally found when doing sigmoidoscopy)
DIVERTICULAR DISEASE is the presence of symptoms because of the diverticulae. Most common in the sigmoid colon
DIVERTICULITIS is the acute onset of inflammation in one or more of the diverticulae
What are the risk factors for diverticular disease?
Diverticular disease is increased with age + poor lifestyle
Low fibre diet
Obesity
Smoking
Drugs (chronic NSAIDS, steroids or opioids)
Age (disease of the elderly, uncommon <40)
How does diverticular disease present?
How does diverticulitis present?
Diverticular disease
- Altered bowel habit – constipation
- Abdominal colic – LEFT sided
- Relieved by defecation (do not confuse with IBS)
- Bleeding
- Nausea + Flatulence
DIVERTICULITIS
- All features above + severe systemic sx
- Pyrexia
- Tachycardic (pain-LIF)
- Tenderness and guarding in LIF (localised or generalised peritonitis)
- Diarrhoea ± Bleeding (melaena)
How does a perforated diverticulum present?
Ileus
Peritonitis
Shock
Requires urgent surgical assessment
How do you classify diverticulitis?
What is the treatment of acute diverticulitis?
Whats the long term managment of diverticulitis?
Hinchley classification to classify diverticulitis
Acute management
- Abx - co-amoxiclav
- Fluids
- Analgesia - avoid opioids
- admission if ?complications or if severe/frail
Long term management
- Lifestyle advice (eat fibre, drink fluids and no smoking)
- Avoid NSAIDS and OPIATES
- Analgesics
- Bulk forming laxatives (not stimulants)
- Anti-cholinergics (reduce cramps by slowing bowel)
- Surgery - depending on degree of infective complications
Difference between Crohn’s and ulcerative colitis:
area affected
superficial/deep
skip lesions?
Crohns:
- any part of GI tract
- most commonly terminal ileum (b12 deff)
- transmural (full thickness of wall)
- skip lesions present
UC:
- large bowel (colon and rectum)
- distal regions worse affected (starts rectum, moves up)
- more superficial
- lesions are constant (no skip lesions)
Gereneal symptoms of IBD?
Difference between Crohn’s and ulcerative colitis: presentation
Both
- Cramps and pain
- Diarrhea and urgency (more common in Chrons)
- Constipation
- Fullness (tenesmes)> more common in UC
- Rectal bleeding
General autoimmune
- Fever
- Reduced appetite
- Weight loss
- Fatigue
- Night sweats
- Problems with your period. You might skip them, or their timing might be harder to predict.
Crohn’s:
- mouth ulcers
- anal fistula/abscess/stricture
- PERNICIOUS Anaemia → SOB (due to ↓B12 absorption ILEUM)
UC: symptoms normally less severe
- mucusy stool
- blood in stool
- IRON DEFF Anaemia → SOB (due to blood loss in stool)
What condition is smoking protective
Smoking is protective in ulcerative colitis
What extra-intestinal symptoms are present in IBD? (bones, eyes, skin)
Specific systemic features of crohns?
Specific systemic features of UC?
Both:
BONES
-larger joint arthritis
-clubbing
SKIN
- erythema nodosum (also caused by strep infection, sarcoidosis, sulfonamides, TB)
- pyoderma gangrenosum (both but more commonly Crohn’s)
- psoriasis
EYES
- episcleritis
- Anterior uveitis
Crohn’s:
- Aphthous ulcers
UC:
- Primary sclerosing cholangitis
What is an acute complication of ulcerative colitis?
What is this?
What blood tests would suggest?
Treatment?
Toxic megacolon = fulminant colitis
-Inflammation> loss of contractility>accumulation of gas and fluid (transverse >6cm) > can perforate
Symptoms:
- Severe abdo pain, ↑WCC, ↑↑CRP, ↓Hb, ↑Platelets (reactive thrombocytosis)
- IV Hydrocortisone (3 d) → surgery if refractory
What investigations are done for IBD?
Stool:
- Stool MSC (rule out infection)
- Faecal calprotectin tests for GI inflammation (if negative there is no inflammation)
Bloods:
- FBC (raised WCC, raised platelets)
- Albumin (low)
- CRP/ESR (raised)
- LFTs (look for PSC-more common in UC)
- U+Es
- Ferritin B12, folate (deficiency-lack of absorption)
- Coeliac serology (anti TTG)
Imaging:
- GOLD STANDARD: Colonoscopy + biopsy
- Abdo Xray (thumb printing and lead piping)
- Chest X ray for perf
- MRI to detect fistulae
Difference between Crohn’s and ulcerative colitis: histopathology
Crohn’s: GOBLET CELLS AND GRANULOMAS
- Transmural granulomatous inflammation -> fibrosis + stenosis -> fistulae + abscesses
- Cobblestone appearance
- Thickened bowel wall
UC: PLASMA CELLS
- Crypt abscesses = defining lesion
- Micro ulcers
- pseudo polyps (surviving mucosa)
- Inflammation is NOT transmural
- dilated thinned bowel wall (toxic megacolon)
What is the treatment for Crohn’s? (remission and maintenance)
Crohns does not include mesalazine (5-ASA)
Smoking cessation*
REMISSION
1st line: glucocorticoid steoids
-oral prednisolone 7 weeks
-IV methylpred if severe
2nd line: can add azathioprine/mercaptopurine if doesnt work. Or biologic (infliximab)
MAINTANANCE
-if mild: just stop smoking
1st line: azathioprine/mercaptopurine (require steroids 2+ times one year)
50% require surgery (not curative)
What is the treatment for ulcerative colitis? (remission and maintenance) TRUE LOVE CRITERIA -mild -moderate -severe
REMISSION
mild (<4 stools a day)
-1st line: PO/PR Mesalazine (5ASA-anti inflam/imunsupp)
-2nd line: add PO/PR prednisolone
moderate (4-6 stools per day but otherwise well)
-Remission on oral steroids
severe (6+ stools per day/anemia/abdo dissension/tachy/albumin ESR>30)
-admit for IV steroids
MAINTAINANCE
- Mesalazine 1st line after mild/mod attack
- Azathioprine 1st line after severe attack (or if steroids needed twice in 1 year)
Others
-Biological agents e.g. anti TNF (infliximab)
-SURGERY- if failing to respond to medical therapy (majority do and undergo remission), surgery is curative
What is mesalazine?When is mesalazine contraindicated?
- 5-aminosalicylic acid (5-ASA)
- contraindicated in aspirin hypersensitivity (both salicylates)
What drugs does mesalazine interact with?
PPIs - they increase the pH so the gastric protection is broken down in the stomach
Lactulose - decreases the pH of stools so it prevents release in the colon
What genes are linked to coeliac disease?
In coeliac what are T cells reacting to?
HLA-DQ2 (95%)
HLA-DQ8
In coeliac, T cells are reacting to gliadin > villous atrophy
*often look for HLA for patients who have changed to non gluten diet before biopsy**
Explain coeliac to a patient.
What symptoms are most common in coeliac disease?
A condition affecting the ability of your bowels to absorb and use nutrients from your food. It is autoimmune (affecting surface area) of intestine) and chronic.
Main symptoms of coeliac disease
- Weight loss/FTT
- Diarrhoea
- Anaemia-iron or b12 deficiency. (ask about dizziness and palpitations and tiredness)
Other symptoms
- Smelly stools - Steatorrhoea - Abdo pain and bloating - N&V - Fatigue and weakness - Angular stomatitis/unexplained iron deficiency
What skin condition is related to coeliac disease?
What is a complication of coeliac?
- Dermatitis herpetiformis
- Osteoporosis can be a complication (malabsorption of nutrients)
What is seen on histology of coeliac disease?
- Villous atrophy
- Crypt hyperplasia
- WBC infiltration
How do you investigate coeliac disease?
All tests must be done whilst eating a gluten-containing diet
-ANTI-TTG and IgG levels
- FBC to check for:
○ Low Hb
○ Low B12
○ Low ferritin
- GOLD STANDARD is Duodenal (or jejunal) biopsy (villous atrophy and crypt hyperplasia)
What is the difference in pathophysiology of nephrotic and nephritic syndrome?
Nephrotic - increased permeability of podocytes in glomerular capillary membrane to plasma proteins»_space; hypoalbuminaemia
Nephritic - decreased membrane permeability due to inflammatory response
What causes nephritic syndrome?
Glomerulonephritis from acute post-streptococcal infection
How dose nephrotic syndrome present?
NAPHROTIC
Na+ decreased (hyponatraemia) Albumin decreased (hypoalbuminaemia) Proteinuria Hyperlipidaemia Orbital oedema Thrombosis (e.g. renal vein thrombosis) Infection (loss of Ig in urine) Coagulability increase (due to loss of antithrombin III in urine)
What immunisations should a patient with coeliac get?
Coeliac UK recommends that everyone with coeliac disease is vaccinated against pneumococcal infection and has a booster every 5 years
How should SEVERE IBD presentation be managed?
If severe presentation IBD- ABCDEF assessment with IV STEROIDS and remember VTE prophylaxis (prone to clots)
What other conditions are asociated with coeliac disease?
GLIAD
- GI:malabsorption, flatus, steatorrhea, vit diff)
- Lymphoma and carcinoma (T cell lymphoma, bowel cancer/breast cancer/bladder cancer)
- Immune associations: IgA deficiency, T1DM, PBC
- Anemia
- Dermatological (dermatitis herpatiformis)
What drugs predispose you to peptic ulcer disease?
PUD
- aspirin
- NSAIDS
- steroids
- anticoagulants
- SSRIS
What are the normal sizes of bowel on x ray
3cm small bowel
6cm for the colon
9cm for the caecum
What abdo x ray findings might you see in UC and Chrons?
AXR
General inflammation: lead piping and thumb printing
UC
-Mucosal islands (pseudo-polyps), Megacolon
Crohns
-stictures
Symptoms of IBS?
What are red flag symptoms indicating that this is not just IBS?
IBS
- recurrent abdo pain assosiated with (2 of following):
- altered stool form
- relieved by defication
- change in frequency
others: bloating/urgency/incomplete emptying/worse after food
Red flags (colonoscopy)
- PR bleeding
- Weight loss/fatigue
- Nocturnal symptoms
- FH of bowel or ovarian cancer
- Change in bowel habit >6 weeks in 55yrs+
What is a really important blood test to do if someone is presenting with IBS symptoms?
If 50 years+ do CA-125 for ovarian cancer
Management of IBS? (consitpation, diarrhoea, bloating)
Management of IBS
Constipation (must avoid lactulose-bloating
- 1st line Bisacodyl + Sodium Picosulfate (stimulants)
Diarrhoea
- Loperamide 2mg after each loose stool
Bloating/colic
-PO anti-spasmodics e.g. Mebeverine
Psychological ONLY IF NO RESPONCE FOR 1 YEAR
-tricyclics e.g. Amitryptaline
