wk 3/4 GI Flashcards
GORD symptoms
- acid reflux
- heart burn
- waterbrash
- often meal related
- postural (when lying down)
investigations of oesophageal disease
- endoscopy or biopsy
- barium swallow test
- oesophageal function test (manometry, pH & impendence monitoring)
reflux oesophagitis
- Result of GORD
- If acid stays in oesophagus long enough people can get erosions of diff. severity
- Graded A-D depending how severe it is/ what percentage of circumference of oesophagus is occupied
barrett’s oesophagus
- Specialised intestinal metaplasia in the lower oesophagus
- Squamous epithelium replaced by columnar epithelium
- Way of defence against acid
- Commonest in obese men >50
- Often asymptomatic
- Premalignant
- Low grade dysplasia -> high grade dysplasia -> adenocarcinoma
- Approx. 0.3% p.a (ie 1/300pt year)
- Surveillance vs. ablation
- Long-term treatment with PPI
gord complications
- Oesophagitis
- Peptic stricture (benign narrowing of oesophagus)
- Barrett’s oesophagus
- Adenocarcinoma
treatment of GORD
- Lifestyle measures (smoking, alcohol, diet, weight reduction)
- Mechanical (posture, clothing, elevate bedhead)
- Antacids
- Acid suppression
- Surgical- fundoplication
achalasia
MOTILITY DISORDER
- Failure of LOS relaxation
- Absence of peristalsis
- Incidence 1/100.000
- Degenerative lesions of oesophageal innervation
- Presents with dysphagia to liquids and solids, weight loss, chest pain
- Endoscopic appearances usually normal
- Can progress to oesophageal dilation and respiratory complications
- Treatment -> BoTox, endoscopic dilation, surgical myotomy, POEM
eosiniphilic oesophagitis
- Common presentation with food bolus obstruction, dysphagia
- Younger age, M>F
- Prevalence 50/ 100,000
- History of atopy (asthma, hay fever)
treatment of eosiniphilic oesophagitis
- Diet – elimination (egg, wheat, milk, nuts, soya, fish)
- Drugs – PPI, tropical sterols (budesonids, fluticasone)
- Dilation – for strictures
oesophageal cancer - adenocarcinoma
- Lower third oesophagus
- Younger
- Reflux (Barrett’s)
- Obesity
- More common
- Increasing
oesophageal cancer - squamous cell carcinoma
- Mid/ upper oesophagus
- Older
- Smoking
- Alcohol
- Less common
- Declining
eosinophilic oesophagitis
- investigations
- Endoscopy – furrows, rings, exudates, strictures
- Biopsy for diagnosis (>15 eosinophils / pof)
6 Biopsies
- 3 from upper, 3 from mid
- If any biopsies there’s more than 15 eosinophils per high-powered field = diagnosis
treatment for H.Pylori
First line (90% efficacy)
- Lansoprazole 30mg 2x a day
- Clarithromycin 500mg 2x day
- Metronidazole 400mg 2x a day
- All 3 for 1 week
Second line if this doesn’t work (85-90% efficacy)
- Another 3 for 1 week
maldigestion
- Impaired breakdown of nutrients, luminal phase (eg pancreatic insufficiency)
malabsorption
- Defective mucosal uptake and transport of adequately digested nutrients. Selective or global
malassimilation
maldigestion + malabsorption
luminal phase of absorption affected by…
Nutrient hydrolysis
- Enzyme deficiency – pancreatic insufficiency
- Enzyme inactivation – ZE syndrome
- Inadequacy of mixing – rapid transit, surgical resection
Fat Solubilization
- Decreased bile salts – cholestasis, cirrhosis
- Bile salt deconjugation – bacterial overgrowth
- Bile salt loss – ileal disease or resection
Luminal availability
- Bacterial consumption of nutrients (bacterial overgrowth) – B12 deficiency
- Decreased intrinsic factor (pernicious anaemia – B12 deficiency
mucousal phase of absorption is affected by…
Brush border hydrolysis
- Lactase deficiency (post gastroenteritis, alcohol, radiation)
Epithelial transport
- Reduced absorptive surface – resection
- Damaged absorptive surface – coeliac disease, tropical sprue, Crohn’s disease, ischaemia
- Infections – Giardia, SIBO
- Infiltration – lymphoma, amyloid
post-mucousal phase of absorption is affected by…
- Post-absorptive processing – lymphatic obstruction
- Lymphangectasia, neoplastic, TB
clinical features of malabsorption
- Diarrhoea and weight loss despite adequate intake
- Bloating, distention, cramps, borborygmi
- Lethargy, malaise
- Symptoms often mild, non-specific
- Malabsorption can be global, or specific nutrients
- Malabsorption syndrome (steatorrhoea, distention, weight loss, oedema) is a RARE presentation
clues of malabsorption in patient history
- Weight loss
- Diarrhoea/ stearorrhea (bile salts and fat)
- Abdominal distention/ gas (carbohydrate)
- Intestinal “angina” (vasculopathy)
- Metabolic bone disease
- GI surgery
- Pancreatitis
- Cystic fibrosis
- Alcohol
- FHx coeliac
clues of malabsorption on examination
- Evidence of malnutrition
- Skin
- Angular cheilitis, glossitis
- Dermatitis herpetiformis
- Oedema
- Neurologic (B12)
- Peripheral neuropathy
- Ataxia (posterior column)
- Psychosis, dementia
laboratory clues of malabsorption
- Microcytosis
- Iron deficiency (common in coeliac, otherwise suspect GI blood loss)
- Macrocytosis
- B12, folate deficiency, but also common in coeliac, alcohol
- Elevated ALP +/- low Ca
- Hypalbuminaemia
- Evidence of multiple deficiencies
main 3 causes of malabsorption
- Coeliac disease
- Pancreatic insufficiency
- Small bowel overgrowth (SIBO) – bacterial overgrowth
coeliac disease general
- Small bowel disorder characterized by
- Mucosal inflammation
- Villous atrophy
- Crypt hyperplasia
- Which occur upon exposure to dietary gluten and which demonstrate improvement after withdrawal of gluten from the diet
symptoms of coeliac disease
- Diarrhoea
- Anaemia
- Dyspepsia
- Abd pain, bloating
- Weight loss
- Mouth ulcers
- Fatigue
- Neuropsychiatric symptoms
clues on investigation - coeliac disease
- Anaemia
- Iron, folate deficiency
- Macrocytosis without anaemia
- Hyposplenic blood film
- Low calcium, elevated alk phos
- Raised transaminases
- Hypalbuminaemia
diagnosis of coeliac disease
- Serological markers
- Anti-tissue transglutaminase antibody (IgA)
(TGG) sensitivity and specificity >95% - Anti-endomysial antibody (IgA)
- Anti-gliadin antibody (IgA, IgG)
- Small intestinal biopsy
treatment for coeliac disease
- Gluten free diet (life-long)
- Dietician
- Nutritional supplements
- Screen for complications
- Bone disease
- Very rarely, need for immunosuppressant medication for refractory cases
pancreatic exocrine insufficiency (PEI)
- Pancreas produces 1.5L/day of bicarbonate and enzyme-rich fluid
- Enzymes for digestion of fat, protein, CHO
- Lipolytic activity declines at first so fat absorption mainly affected
- Overt clinical consequences unlikely unless 90% function loss
- Steatorrhea, weight loss, vit. Deficiency (A, D, E, K) also more minor symptoms
causes of PEI
- Chronic pancreatitis (alcohol)
- Pancreatic cancer
- Cystic fibrosis
- Haemochromatosis
- Pancreatic resection
- Gastric resection
PEI diagnosis
- Risk factors (alcohol, CF)
- Symptoms
- Pancreatic imaging (CT, MRI)
- Tests of exocrine pancreatic function
- Direct – eg secretin stimulation tests
- Indirect – eg faecal elastase, pancreolauryl (only reliably detect mod. To severe PEI)
PEI treatment
- Pancreatic enzyme replacement
- Taken with meals and snacks
- Gastric acid suppression
- Vitamin supplements
small intestinal bacterial overgrowth (SIBO)
- Normally 10^5 to 10^9 bacteria/ml present in distal small bowel
- Colon has up to 10^12
- Older patients, immunosuppressed, disturbed function/ anatomy of gut
- Mostly gram- aerobic bacteria in ileum, gram+ anaerobic bacteria in colon
- In bacterial overgrowth this balance is lost
- Bacteria moves up to s. intestine
- Competes for food
causes of SIBO
- Stasis (stop in flow of gut)
- Strictures
- Crohn’s disease
- TB
- Hypomobility
- Old age
- Opiate analgesics
- Diabetes
- Systemic sclerosis
Blind loops, diverticulae
- Used to be common, now more common again
- Bacteria less likely to be flushed through
- As a result of gastric surgery for peptic ulcer disease
- Now patients with obesity having surgery
- Immunodeficiency
- Obesity?
diagnosis of SIBO
- Quantative culture of jejunal fluid is gold standard
- Glucose/ hydrogen breath test
- More practical
- Oversenstive
- Small bowel radiology to look for anatomical abnormalities
SIBO treatment
- Treatment with 2 weeks of antibiotics
- Eg tetracycline, ciprofloxacin, rifaximin
- Often needs repeat treatments
bile acid malabsorption (BAM)
- Bile acids specifically absorbed in ileum
- Cause secretory diarrhoea in colon
- Affected by ileal disease or resection
- Also impaired in post-cholecystectomy, rapid transit and other malabsorptive states
- Primary BAM may reflect over-production rather then malabsorption
