Small Bowel Pathology Flashcards
What is Irritable Bowel Syndrome?
Chronic functional bowel disorder in the absence of identifiable structural pathology
What is the difference between structural and functional disease?
Structural GI disease is when there is detectable pathology, whereas functional is no detectable pathology
How common is IBS?
Common, affecting 20% of the population
What group does IBS affect more?
F>M
What are the causes of IBS?
Idiopathic
Post-infective
Stress
Adverse life events
Anxiety
Depression
How does IBS present?
Diarrhoea
Constipation
Fluctuating bowel habit
Frequent stools
Mucus
Abdominal pain, relieved by defaecation
Bloating/distention
Belching
Symptoms are made worse by eating and improved by opening bowels
What inestigations are used in IBS diagnosis?
Colposcopy, to exclude other pathology
FIT, to exclude bowel cancer
Anti-TTG, to exclude coeliac
Stool culture, to exclude infective cause
Rectal examination
Calprotectin, to exclude IBD
FBC, CRP, ESR normal
What is the non-pharmacological management of IBS?
Low FODMAP diet
Regular small meals
Limit caffeine and alcohol
Reduced processed foods
CBT
What is the first line pharmacological management of IBS?
Probiotics, for bloating, trial for 4 weeks
Laxatives, for constipation
Antimotility agents, for diarrhoea
Anti-spasmodic agents, for cramps
What is the first line anti-motility agent in IBS?
Loperamide
What laxative should be avoided in IBS?
Lactulose, as can cause bloating
What laxative is used for IBS patients not responding to convential laxatives?
Linaclotide
What is the first line anti-spasmodic in IBS?
Buscopan
What is the second line pharmacological management for IBS?
TCA
What is the third line pharmacological management for IBS?
SSRI
What is Coeliac disease?
Autoimmune condition characterised by sensitivity to the gliadin fraction of gluten, found in wheat, rye, barley and contaminated oats
Where does coeliac mainly occur and why?
Occurs mainly in the duodenum, perhaps as first to be exposed to gluten
But affects the jejunum the most
Describe the pathophysiology of coeliac disease
Anti-TTG and anti-EMA antibodies are created in response to gluten, that target epithelial cells of the intestine, leading to inflammation and villious atrophy
What age does coeliac disease tend to peak?
Usually develops in childhood but can begin at any age
How does coeliac disease present?
Chronic diarrhoea
Bloating/abdominal distention
Weight loss, due to malabsorption
Fatigue and anaemia
Dermatitis Herpetiformis
Clubbing
Mouth ulceration
Reduced fertility
Rarely can present with neurological symptoms
What is dermatitis herpetiformis?
Chronic skin condition characterised by blistering and itchiness typically on the abdomen
What condition is also tested for in new cases of coeliac?
DM1 as conditions are often linked
What investigations are used in coeliac diagnosis?
Distal duodenal biopsy
- Villious atrophy/collapsed villi
- Crypt hypertrophy
Antibodies
- Raised anti-TTG
- Raised anti-EMA
Total IgA levels
Why does plasma IgA have to be tested before testing coeliac antibodies?
As anti-TTG and anti-EMA antibodies are a type of IgA, if total IgA is low/patient is deficient in IgA, coeliac test will be negative even if they have coeliac
For these patients, use IgG version of antibodies instead
What should a patient do before confirming a diagnosis of coeliac?
Patient must be eating gluten in more than 1 meal a day for 6 weeks, otherwise serology and biopsy may be negative
What is the management for coeliac?
Lifelong guten free diet
Coeliac antibody monitoring
Pneumococcal immunisation, due to hyposplenism
What conditions are associated with coeliac?
DM1
Thyroid disease
Autoimmune hepatitis
Primary biliary cirrhosis
Primary sclerosing cholangitis
Name some complications of coeliac disease
Refractory coeliac disease
Anaemia (Folate, iron and B12 deficiency)
Osteoporosis
Small bowel adenocarcinoma
Lymphoma
Functional hyposplenism
Give features of angiodysplasia
Vascular malformation of the gut
Occasional rectal bleeding
Fatigue
Dyspnoea
Colonoscopy shows scattered bright lesions with branching appearance of vessels from central vessel
How is angiodysplasia managed?
Interventional endoscopy
- Adrenalin injection
- Photocoagulation
- Clipping
What is acute mesenteric ischaemia?
Acute disruption of blood supply to small bowel
How is acute mesenteric ischaemia managed?
Emergency laparotomy
What causes small bowel obstruction?
Intra-abdominal adhesions, due to previous surgery
Incarceration of hernias
Malignancy
IBD
How does small bowel obstruction present?
Central abdominal pain
N&V, early
Constipation, late
Abdominal distention
Tinkling/high pitched bowel sounds
How is small bowel obstruction managed?
IV fluids
NG tube
Emergency laparotomy
Differentiate between small and large bowel obstruction
In small, there is early onset N&V
In large, there is late onset N&V
What investigations are used in small bowel obstruction?
AXR, first initial investigation
- Dilated bowel loops
CT, diagnostic investigation
Erect CXR
- Pneumoperitoneum, if perforation
What is the most common cause of small bowel obstruction?
Adhesions
What is Peutz-Jeghers syndrome?
Autosomal dominant condition characterised by numerous hamartomatous polyps within the gastrointestinal tract, along with pigmented freckles on the lips, face, palms and soles
What is the most appropriate initial investigation to assess presence of free fluid within the abdomen?
FAST scan
CT is useful in the assessment
Give features of carcinoid tumours
Appendix and small bowel are common origins
Serotonin secretion
Abdominal pain and diarrhoea
Flushing
Wheeze
Pulmonary stenosis
What investigations are used in carcinoid tumours?
Raised urinary 5-HIAA
How are carcinoid tumours managed?
Octreotide/somatostatin analogue that blocks serotonin release and counters its peripheral effects
Give features of whipples disease
Systemic condition caused by Tropheryma whipplei
Diarrhoea and weight loss
Joint pain
Memory loss
Acid-Schiff (PAS)-positive macrophages on duodenal biopsy
How is whipples disease managed?
Co-trimoxazole
