IBS + GORD + MW Tear + Oesophageal Varices

Question 1

What does IBS stand for?
what is it?

Answer 1

Irritable bowel syndrome
‘Functional’ chronic bowel disorder

Question 2

What is IBS related to?

Answer 2

Psychology (stress, anxiety, poor diet), 3+ months GI Sx with NO UNDERLYING CAUSE (everything ruled out)

Question 3

What are the 3 types of IBS?
What are they mostly?

Answer 3

IBS-C = Mostly Constipation
IBS-D = Mostly Diarrhoea
IBS-M = Mostly mixed, alternating C/D

Question 4

Symptoms of IBS

Answer 4

Abdo pain + bloating RELIEVED BY DEFACATION (going for poo)
Altered stool form/frequency

Question 5

Diagnosis of IBS

Answer 5

Exclusions - exclude coeliacs (serology), IBD (fecal calprotectin) & infection (high ESR/CRP/blood cultures)

Question 6

Treatments of IBS

Answer 6

1. Conservative - Patient education + reassurance eg. IBS-C = More fibre
2. Moderate -
   IBS-C = Laxatives (Senna)
   IBS-D = Anti motility drug (loperamide)
3. Severe - TCA (tricyclic antidepressants) eg. Amitriptyline (relieves pain and changes bowel activity + consider CBT/GI referral

Question 7

Definition of GORD

Answer 7

Gastric reflux into oesophagus due to decreased pressure across lower oesophageal sphincter (LOS) causes Oesophagitis

Question 8

Causes of GORD

Answer 8

Increased intraabdominal pressure (obesity, pregnancy)

Hiatial Hernia (mostly with sliding - stomach & oesophagus LOS slide up through oesophageal hiatus, an opening in diaphragm)

Drugs - eg. anti mucarinics

Scleroderma (muscle replaced with connective tissue,
LOS = Scarred)

Question 9

Pathology of GORD

Answer 9

decreased LOS pressure = more potential for free up passage of acid

Question 10

Symptoms of GORD

Answer 10

“Heartburn” = retroperitoneal burning chest pain
chronic cough and nocturnal asthma
Dysphagia (difficulty swallowing) - bad sign

Question 11

When are Sx worse?

Answer 11

when lying down, acid easier to reflect this way

Question 12

Diagnosis of GORD

Answer 12

If no red flags = go straight to treatment (Dx = clinical)

Red Flags (dysphagia, haematemesis (vomit blood), weight loss)
Endoscopy = Oesophagitis or barretts
Oesophageal manometry = measure LOS pressure + monitor gastric pH

Question 13

Treatment of GORD

Answer 13

1. Conservative lifestyle change (smaller meals, 3+ hours before bed)
2. PPI (or H2RA if CI)
   Antacids - SE = Diarrhoea (neutralise acid)
   Alginates - Gaviscon (symptomatic)

Last resort = Surgical tightening of LOS - Nissen fundoplication = Wrap kudus around LOS externally to increase pressure across it

Question 14

What are the 2 complications of GORD

Answer 14

Oesophageal strictures (tightening of oesophagus)
Barretts oesophagus

Question 15

What are oesophageal strictures?
what are the typical patients looking like?
Sx and treatment?

Answer 15

Tightening of oesophagus
usually 60+ Px, progressively worse dysphagia
Tx = oesophageal dilation (endoscopic) + PPI

Question 16

Barrets oesophagus
How many GORD patients develop this?
What cause does it always involve?
What is the pathology?
Typical Patient and Sx?
Diagnosis?

Answer 16

10% GORD Px develop this

Always involves Hiatal Hernia

Metaplasia (stratified squamous non keratinising epithelium –> simple columnar)

increased risk of adenocarcinoma

Normal –> Metaplasia (Barrets) –> Dysplasia (Adenocarcinoma)

Middle aged caucasian male with history of GORD and progressively worsening dysphagia

Dx with biopsy

Question 17

Mallory Weiss Tear
Definition

Answer 17

Linear lower oesophageal mucosal tear due to sudden increased abdominal pressure

Question 18

MW Tear
Typical patient? and Sx?

Answer 18

Presents typically as young male with acute history of retching (eg. after night out) eventually causing haematemesis

Question 19

MW Tear
RF?

Answer 19

Alcohol, Chronic cough, bullemia, ‘hyperemesis gravidarum’ - pregnancy complication of severe N+V - much worse than morning sickness, weight loss and dehydration

Question 20

What is there no history of?

Answer 20

Liver disease or pulmonary hypertension
Pul HTN = think oesophageal varices rupture
No liver Hx, retching Hx - think MW tear

Question 21

Symptoms of MW Tear

Answer 21

Haematemesis (after retching/vomiting Hx)
Hypotensive if severe (often mild therefore this is unlikely)

Question 22

Diagnosis of MW Tear

Answer 22

OGD (Endoscopy) to confirm
ROCKALL SCORE = for severity of upper GI bleeds

Question 23

Treatment of Tear

Answer 23

Most spontaneously heal within 24hrs

Question 24

What are oesophageal varices?

Answer 24

enlarged veins that protrude into the oesophagus

Question 25

What causes oesophageal varices?

Answer 25

hypertension in portal venous system due to underlying liver issues

Question 26

What happens when vein ruptures?

Answer 26

causes large amounts of bleeding

Question 27

Sx of oesophageal varices?

Answer 27

haematemesis (quite alot of blood)
abdo pain
system = shock, hypotension, pallor

Question 28

Dx?

Answer 28

endoscopy

Question 29

Tx for acute bleed?

Answer 29

EMERGENCY
1. ABCDE
2. Vasopressin (terlipressin) for vasocontriction
3. bleeding abnormality = vit K
4. Surgery = endoscopic varicoceal band ligation (within 24hrs)

Question 30

Tx if no bleed?

Answer 30

1. beta blocker (propanolol)
2. endoscopic varicoceal band ligation