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Year 3 > Week 13 - Coeliac, Colorectal cancer, Diverticular Disease, Colitis, Diarrhoea, Intestinal obstruction, IBS, ischaemia and gastroenteritis > Flashcards

Week 13 - Coeliac, Colorectal cancer, Diverticular Disease, Colitis, Diarrhoea, Intestinal obstruction, IBS, ischaemia and gastroenteritis Flashcards

C

1
Q

What is coeliac disease

A

It is an autoimmune condition triggered by eating gluten.

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2
Q

Who do we always test for coeliac disease

A

Always test new cases of type 1 diabetes and autoimmune thyroid disease for coeliac even if they do not have symptoms.

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3
Q

What do the antibodies in coeliac disease target and what does this lead to
n

A

Epithelial cells in the small intestine, leading to inflammation

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4
Q

What are the three antibodies particularly related to coeliac disease

A

Anti-tissue transglutaminase antibodies (anti-TTG)
Anti-endomysial antibodies(anti-EMA)
Anti-deamidated gliadin peptide antibodies(anti-DGP)

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5
Q

Where does this inflammation affect

A

The small bowel, particularly the jejunum. The surface of the small intestine is inverted in projections called villi which increase the surface area and help with nutrient absorption.

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6
Q

Coeliac disease causes what to happen to the intestinal villi and what does this result in

A

Coeliac disease causes atrophy of the intestinal villi, resulting in malabsorption

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7
Q

What are the HLA genotypes that coeliac disease is associated with

A

HLA-DQ2
HLADQ8

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8
Q

What is the presentation of coeliac disease

A

Often asymptomatic and is under-diagnosed, so have a low threshold for testing. Presenting symptoms include:
failure to thrive in young children
Diarrhoea
Bloating
Fatigue
Weight loss
Mouth ulcers

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9
Q

What is the rash seen in coeliac disease and where is it found

A

Dermatitis herpetiformis is an itchy blistering skin rash, typically on the abdomen, caused by coeliac disease

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10
Q

What occurs secondary to malabsorption and deficiency of iron, B12 and folate

A

Anaemia

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11
Q

What are the neurological symptoms that coeliac disease can present with

A

Peripheral neuropathy
Cerebelar ataxia
Epilepsy

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12
Q

What must the patient do when being investigated for gluten intolerance

A

Patient must continue to eat gluten. Antibodies and histology may be normal if the patient is gluten free.

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13
Q

What are the first line blood tests done for coeliac disease?

A

Total immunoglobulin A levels (to exclude IgA deficiency)
Anti-tissue transglutaminase antibodies (anti-TTG)

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14
Q

What is the second line option where there is doubt

A

Anti-endomysial antibodies (anti-EMA)

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15
Q

How is the diagnosis of coeliac disease confirmed

A

Diagnosis is confirmed by endoscopy and jejunal biopsy

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16
Q

What are the typical biopsy findings

A

Crypt hyperplasia
Villous atrophy

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17
Q

How is Coeliac disease managed

A

A lifelong gluten free diet should completely resolve the symptoms.

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18
Q

What are the complications of coeliac disease?

A

Nutritional deficiencies
Anaemia
Osteoporosis
Hyposplenism (with immunodeficiency, particularly to encapsulated bacteria such as Streptococcus pneumoniae)
Ulcerative jejunitis
Enteropathy-associated T-cell lymphoma (EATL)
Non-Hodgkin lymphoma
Small bowel adenocarcinoma

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19
Q

What are the factors that increase the risk of colorectal cancer?

A

family history of bowel cancer
FAP or HNPCC
Crohn’s disease or ulcerative colitis
Increased age
Diet
Obesity and sedentary lifestyle
Alcohol and smoking

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20
Q

What is FAP

A

An autosomal dominant condition involving malfunctioning of the tumour suppressor genes called APC. It results in many polyps (adenomas) developing along the large intestine.

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21
Q

What is it called when patients get their entire large intestine removed?

A

Panproctocolectomy

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22
Q

What is HNPCC also known as

A

Lynch Syndorme

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23
Q

What is HNPCC

A

An autosomal dominant condition that results from mutations in DNA mismatch repair genes. Patients are at higher risk of cancers, but particularly colorectal cancer

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24
Q

What are the red flags to look out for when considering bowel cancer

A

changes in bowel habits
Unexplained weight loss
Rectal bleeding
Unexplained abdominal pain
Iron deficiency anaemia
Abdominal or rectal mass on examination.

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25
Q

What are the NICE guidelines for the two week wait for colorectal cancer

A

over 40 yrs with abdominal pain and unexplained weight loss
Over 50 yrs with unexplained rectal bleeding
Over 60 yrs with a change in bowel habit or iron deficiency anaemia

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26
Q

What is a FIT test

A

Faecal immunochemical test - look specially for the amount of human haemoglobin in the still.

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27
Q

What is the screening programme used in England

A

In England, FIT tests are used for bowel cancer screening, people aged 60-74 are sent a home FIT test to do every 2 years. If the results are positive they are sent for a colonoscopy

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28
Q

What is the gold standard investigation for colorectal cancer

A

Colonoscopy - it involves an endoscopy to visualise the entire large bowel.

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29
Q

What does a staging CT scan involve

A

Involved a full CT thorax, abdomen and pelvis (CT TAP). It is used to look for metastasis and other cancers. It may be used after a diagnosis of colorectal cancer

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30
Q

What is the tumour marker blood test for bowel cancer

A

Carcinoembryonic antigen (CEA). This is not helpful in screening, but it may be used for predicting relapse in patients previously treated for bowel cancer.

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31
Q

What is low anterior resection syndrome

A

May occur after resection of a portion of bowel from the rectum, with anastomosis between the colon and rectum. It can result in a number of symptoms including:
urgency and frequency of bowel movements
Faecal incontinence
Difficulty controlling flatulence

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32
Q

What is the follow up following curative surgery - what does this include

A

serum CEA
CT TAP

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33
Q

What is the first line constipation drug for children

A

Movicol is first line laxative for children

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34
Q

What is a diverticulum

A

Is a pouch or pocket in the bowel wall, usually ranging in size from 0.5-1cm.

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35
Q

What does diverticulosis refer to

A

The presence of diverticula, without inflammation or infection.

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36
Q

What is diverticulitis

A

Refers to inflammation and infection of diverticula

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37
Q

Why do diverticula not form in the rectum

A

Because it has an outer longitudinal muscle layer that completely surrounds the diameter of the recutm, adding extra support.

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38
Q

Where does diverticulosis most commonly affect in the bowel

A

The sigmoid colon, however it can affect the entire large intestine in some patients.

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39
Q

What increases the risk of getting diverticulosis

A

Increased age, low fibre diets, obesity and the use of NSAIDs.

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40
Q

How is diverticulosis often diagnosed

A

Often diagnosed incidentally on colonoscopy or CT scans. Treatment is not necessary where the patient is asymptomatic. However, advice regarding a high fibre diet and weight loss is appropriate

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41
Q

What are the symptoms of diverticulosis

A

May cause lower left abdominal pain, constipation or rectal bleeding.

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42
Q

What is the management of diverticulosis

A

Increased fibre in the diet and bulk-forming laxatives. Stimulant laxatives should be avoided.

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43
Q

What does acute diverticulitis present with:

A

pain and tenderness in LIF
Fever
Diarrhoea
Nausea and vomiting
Rectal bleeding
Palpable abdominal mass
Raised inflammatory markers

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44
Q

What is the management of uncomplicated diverticulitis in primary care:

A

oral co-amoxiclav for at least 5 days
Analgesia - avoid NSAIDs
Only taking clear liquids and avoid solid food
Follow up within 2 days

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45
Q

What happens to patients with severe pain or complications with diverticulitis

A

They go to hospital and receive;
NBM
IV antibiotics
Analgesia
IV fluids
Urgent investigations (CT scan)
Urgent surgery may be required for complications.

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46
Q

What are the complications of acute diverticulitis

A

perforation
Peritonitis
Peridiverticular abbess
Large haemorrhage requiring blood transfusions
Fistula
Ileus / obstruction

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47
Q

what is the treatment for infective colitis

A

rehydrate with oral or IV solution keeping a close eye on electrolytes and replace as required.

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48
Q

what is diarrhoea defined as

A

the passage of a lose liquid stool

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49
Q

what kind of diarrhoea is always pathological

A

bloody diarrhoea is always pathological and will nearly always be caused by some form of colitis

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50
Q

what may diarrhoea that develops in the hosptial be due to

A

C.difficile infection

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51
Q

what is the named endocrine cause of diarrhoea

A

hyperyhyroidism

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52
Q

what are the 3 causes of infective diarrhoea

A

bacterial
viral
parasitic

53
Q

what are the 4 types of bacterial diarrhoea

A
  • e coli (most common)
  • salmonella
  • shigella
  • campylobacter
54
Q

what are the 2 viral causes of infective diarrhoea

A

Rotovirus – this is THE most common cause of diarrhoea

Norovirus – an umbrella term for a range of similar viruses

55
Q

what are the 3 causes for parasitic infective diarrhoea

A

Amoebic dysentery – caused by Entamoeba histolytica

Giardiasis – caused by Giardia

Cryptosporidium

56
Q

what are the 3 common types of diarrhoea when travelling

A

cholera - highly dangerous

e.coli

guarduasus

57
Q

how does clindamycin cause diarrhoea

A

this is a broad spectrum antibiotic (and the same affect may be seen in other broad spectrum ABs)

it will kill almost all bacteria in the gut. the problem is that this then allows resistant C.difficile to proliferate and cause diarrhoea

58
Q

how does erythromycin cause diarrhoea

A

this increases gut motility, it is sometimes even used to treat constipation

59
Q

how does penicillin cause diarrhoea

A

breakdown products of this act as an osmotic laxative

60
Q

how does tetracylcin cause diarrhoea

A

this has an effect on fat absorption and thus leads to diarrhoea

61
Q

how does neomycin lead to diarrhoea

A

Neomycin – this affects bile salt absorption and thus the bile salts act as an osmotic laxative and draw fluid into the lumen.

62
Q

what metabolic disorders cause diarrhoea

A

hyperthyroidism
thyrotoxicosis
anxiety
peptides secreted by unsusual tumours

63
Q

what are the 3 small bowel diseases that cause diarrhoea

A

Crohn’s disease
coeliac disease
blind loop syndrome

64
Q

what are the 5 large bowel disease causes of diarrhoea

A

UC
colon cancer
IBS
spurious
polyps and diverticular disease

65
Q

what are the investigations used in the queiry of diarrhoea cause

A

FBC – to check for leukocytosis (for infective causes and colitis) and anaemia
Anti α-gliadin Abs – test for coeliac’s disease
Thyroid function tests – check for hyperthyroidism
Stool culture – check for infections; don’t forget microscopy for parasites
Proctoscopy / sigmoidoscopy – cancer / colitis and polyps
Flexible sigmoidoscopy / colonoscopy – if protoscopy does not deliver enough detail.
Small bowel enema – can see Crohn’s coeliac’s and Whipple’s disease
ERCP – can see pancreatic insufficiency.

66
Q

what is ileus

A

a condition affecting the small bowel, where the normal peristalsis that pushes the contents along the length of the intestines, temprrarily stops.

67
Q

what is the term used to describe a functional obstruction of the large bowel

A

a pseudo-obstruction

68
Q

what are the causes of ileus

A

Injury to the bowel

Handling of the bowel during surgery

Inflammation or infection in, or nearby, the bowel (e.g., peritonitis, appendicitis, pancreatitis or pneumonia)

Electrolyte imbalance (e.g., hypokalaemia or hyponatraemia)

69
Q

what is the most common time you will see ileus

A

following abdominal surgery. this usually resolves with supportive care within a few days

70
Q

what are the signs and symptoms of ileus

A

Vomiting (particularly green bilious vomiting)

Abdominal distention

Diffuse abdominal pain

Absolute constipation and lack of flatulence

Absent bowel sounds (as opposed to the “tinkling” bowel sounds of mechanical obstruction)

71
Q

what is the management of ileus

A

the ileus will usually resolve with treatment of the underlying cause. management involves supportive care.

72
Q

what does supportive care for ileus include

A

Nil by mouth or limited sips of water

NG tube if vomiting

IV fluids to prevent dehydration and correct the electrolyte imbalances

Mobilisation to helps stimulate peristalsis

Total parenteral nutrition (TPN) may be required whilst waiting for the bowel to regain function

73
Q

what kind of diagnosis is IBS

A

a diagnosis of exclusion

74
Q

what are the red flag symptoms of IBS that would suggest a more serious underlying cause

A

Rectal bleeding
Age >50 at first presentation
Family history of bowel or ovarian cancer
Iron deficiency anaemia
Unexplained weight gain or weight loss

75
Q

what is the differential diagnosis for IBS

A

Bowel cancer
Ovarian Cancer
Coeliac disease
Inflammatory bowel disease
Infective colitis

76
Q

what are the general symptoms of IBS

A

nausea alone
vomiting alone
bleching
chest pain
abdominal discomfort and bloating
young patients
frequent bowel actions
no weight gain

77
Q

what are the gynaecological manifestations of IBS

A

painful periods and pain after sex

prementrual tension

78
Q

what are the urinary symptoms associated with IBS

A

frequency
urgency
nocturia
incomplete emptying of the bladder

79
Q

what is the most common cause of GI referral in the UK

A

IBS

80
Q

are men or women more affected

A

women are 2-3 times more affected

81
Q

what is the Rome criteria used for

A

set of criteria that attempt to define the symptoms of functional bowel disorders. using the criteria, you can put sufferers into different categories in an attempt to tailor their treatments

82
Q

what does the Rome criteria state

A

the criteria state that in the preceeding 12 months, there should be at least 12 consecutive weeks of abdominal pain and discomfort with at least two of the following:

  • pain relieved on defecation
  • onset associated with a change in frequency of stool
  • onset associated with change in appearance of the stool
83
Q

what are the 5 types of functional bowel disorders

A

IBS
functional abdominal bloating
functional constipation
functional diarrhoea
functional abdominal pain

84
Q

what is neurosis

A

a condition that causes psychological distress, but unlike psychosis it does not prevent or affect rational thought. In neurotisism, symptoms are interpreted more negatively than the general population

85
Q

what sort of pain will most IBS sufferers have

A

colicky LLQ pain that is relieved on defecation

they also tend to have diarrhoea and constipation regularly

86
Q

what do tests and investigations do in IBS

A

they do not confirm the diagnosis but they can rule out other conditions

often a diagnosis can be made based on history and clinical diagnosis alone without the need for further investigations

87
Q

what does any sign of mucosal inflammation mean

A

this means it is NOT IBS

88
Q

what is a sign of long term laxative use

A

pigmented mucosa in the rectum (melanosis coli)

89
Q

what is the most popular theory of pathophysiology behind iBS

A

neuromuscular dysfunction

basically this theory states that patients that have IBS have some sort of neuromuscular abnormalities that affect normal gut motility. the problem is there isnt much evidence for this. there is some evidence that shows there is increased colonic activity in those with IBD, but how this relates to symptoms is uncertain.

90
Q

what is the visceral hypersensitivity theory

A

this is another popular theory and states that nervous sensitivity in the gut is somehow enhanced in people with IBD. This would make sense, because many IBD patients report increased pain response to rectal distension (e.g. during the colonoscopy). The sensitivity appears to be visceral specific – i.e. there is no increased cutaneous hypersensitivity. It is also uncertain as to whether this hypersensitivity exists as a result of abnormal mechanoceptor functioning, or as a result of abnormal sensory processing by the brain and spinal chord.

91
Q

in 50% of IBS conditions, what relieves the symptoms

A

a placebo

92
Q

what is given for persistent diarrhoea

A

loperamide - 2mg

93
Q

what is given for persistent constipation

A

osmotic laxative - movicol, lactulose

avoiding stimulant laxatives

94
Q

what is mesenteric ischaemia caused by

A

lack of blood flow through the mesenteric vessels supplying the intestines, resulting in intestinal ischaemia

95
Q

what are the three main branches of the abdominal aorta that supply the abdominal organs

A

coeliac artery
superior mesenteric artery
inferior mesenteric artery

96
Q

what does the foregut include

A

stomach, part of the duodenum, biliary system, liver, pancreas and spleen

97
Q

what is the foregut supplied by

A

the coeliac artery

98
Q

what is the midgut formed of

A

distal part of the duodenum, to the first half of the tranverse colon.

99
Q

what is the midgut supplied by

A

the superior mesenteric artery

100
Q

what is the hindgut made up of

A

second half of the transverse colon to the rectum

101
Q

what is the hindgut suppled by

A

inferior mesenteric artery

102
Q

what is chronic mesenteric ischaemia

A

result of narrowing of the mesenteric blood vessels by atherosclerosis.

this results in intermittent abdominal pain, when the blood supply cannot keep up with the demand. similar to angina

103
Q

what is the typical triad presentation of chronic mesenteric ischaemia

A

Central colicky abdominal pain after eating (starting around 30 minutes after eating and lasting 1-2 hours)

Weight loss (due to food avoidance, as this causes pain)

Abdominal bruit may be heard on auscultation

104
Q

what are the risk factors for chronic mesenteric ischaemia

A

Increased age
Family history
Smoking
Diabetes
Hypertension
Raised cholesterol

105
Q

what is diagnosis of chronic mesenteric ischaemia confirmed with

A

CT angiography

106
Q

what does management of chronic mesenteric ischaemia include

A

reducing modifiable risk factors

secondary prevention - statins and antiplatelets

revascularisation to improve the blood flow to the intestines

107
Q

what is acute mesenteric ischaemia

A

typically caused by a rapid blockage in blood flow through the superior mesenteric artery

this is usually caused by a thrombus

108
Q

what is a key risk factor of acute mesenteric ischaemia

A

atrial fibrillation where a thrombus forms in the left atrium, then it mobilises down the aorta to the SMA where it becomes stuck and cuts off the blood supply

109
Q

what is the diagnostic test of choice for acute mesenteric ischaemia

A

Contrast CT

patients will have metabolic acidosis and raised lactate level due to ischaemia

110
Q

what is the mortality rate for acute mesenteric ischaemia

A

very high mortality rate - 50%

111
Q

what is acute gastritis

A

is stomach inflammation and presents with epigastric discomfort, nausea and vomiting

112
Q

what are the most common causes of gastroenteritis

A

viruses.

113
Q

what specific viruses cause gastroenteritis

A

Rotavirus
Norovirus
Adenovirus (tends to cause respiratory symptoms)

114
Q

what is E.coli

A

produces the Shiga toxin. this leads to abdominal cramps, bloody diarrhoea and vomiting.

115
Q

what does e.coli lead to when it produces the Shiga toxin

A

destroys red blood cells, leading to haemolytic uraemic syndrome (HUS)

116
Q

why are antibiotics avoided if E.coli is suspected

A

because the use of antibiotics increases the risk of haemolytic uraemic syndrome

117
Q

what is a common cause of traveller’s diarrhoea

A

Campylobacter

118
Q

how is Campylobacter spread

A

Raw or improperly cooked poultry
Untreated water
Unpasteurised milk

119
Q

how long is the incubation period for campylobacter

A

Incubation is usually 2 to 5 days. Symptoms resolve after 3 to 6 days

120
Q

what are the symptoms of campylobacter

A

Abdominal cramps
Diarrhoea often with blood
Vomiting
Fever

121
Q

what is first line for campylobacter

A

clarithromycin

122
Q

when may you come across bacillus cereus

A

with infective endocarditis in IV drug users where heroin is contaminated.

123
Q

what is the most common cause of infective endocarditis in intravenous drug users

A

staph aureus

124
Q

eating raw or undercooked pork can cause what kind of infection

A

Yersinia enterocolitica is a gram-negative bacillus.

125
Q

what is giardiasis treated with

A

Treatment is with tinidazole or metronidazole.

126
Q

is food poisoning a notifiable disease

A

yes - the UKHSA should be notified.

127
Q

what kind of drugs are avoided in viral gastroenteritis

A

antidiarrhoeal drugs and antiemetics are they worsen the condition.

The NICE Clinical Knowledge Summaries (updated June 2023) suggest antidiarrhoeal drugs may be helpful in mild-moderate diarrhoea but should be avoided with E. coli 0157, shigella or bloody diarrhoea.

128
Q
A

Year 3 (63 decks)

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