Gastro - Lower GI Tract

Question 1

what are the 2 subtypes of IBD

Answer 1

ulcerative colitis
Chronns disease

Question 2

what is Ulcerative colitis

Answer 2

Diffuse mucosal inflammation limited to the colon

Question 3

what is proctits

Answer 3

UC which is confined to the rectum

Question 4

what is crohns disease

Answer 4

transmural disease - goes through the mucosal wall
occures from mouth to anus

Question 5

what is incidence of crohns compared with UC

Answer 5

more crohns
can occur at any age
peak between 10-40

Question 6

what causes IBD

Answer 6

smoking - for crohns
drugs - NSAIDS and abx
gut flora
diet
hygiene
appendix
geography
stress
infections
etc - more found every year

Question 7

what are the resenting symptoms of UC

Answer 7

Frequent bloody diarrhoea
Mucus pr
Tenesmus - feel need to poo
Abdominal pain
Fever

Question 8

crohns presenting symptoms

Answer 8

Fatigue
Weight loss
Fever
Diarrhoea +/- bleeding
Pain
Vomiting
Bloating
Fistula
Abscess

Question 9

important things to know in history

Answer 9

Previous episodes
Family history - 10% if 1 parent 40% if both parents
Smoking
Appendicectomy
Travel
Contacts
Antibiotics/NSAIDs
Extra-intestinal manifestations

Question 10

what are the key signs of IBD

Answer 10

Pyrexial
Tachycardic
Dehydrated
Pale
Tender abdomen
PR/rigid sigmoidoscopy

Question 11

what initial investigations should be done (A and E)

Answer 11

Blood tests
Anaemia - B12 deficiency, blood loss, malnutrition of folate
Thrombocytosis - bleeding and inflammation
Raised ESR and CRP
Hypoalbuminaemia

Microbiology
Stool cultures and Clotridium difficile assay
giardia, campylobacter and E coli

Question 12

what is this

Answer 12

pseudopolyps

Question 13

what is this

Answer 13

pseudomembranous colitis
C.diff

Question 14

whats wrong

Answer 14

featureless drainpipe colon (thin black line)

Question 15

whats wrong

Answer 15

inflammed enlarged colon - gas patters seppareated by oedema in the bowel
thumbprinting

Question 16

whats wrong

Answer 16

obstruction
large bowela dn small bowel have fluid levels
likely cancer but maybe crohns

Question 17

whats wrong

Answer 17

small bowel obstruction

Question 18

whats wrong

Answer 18

fistula
gas in the urinary bladder - pneumaturia
stool goes into bladder

Question 19

what is some differential diagnosies of infection of the bowel

Answer 19

Gastroenteritis/dysentery
Clostridiodes difficile
Amoebiasis
Tuberculosis
CMV- can reactivate
Yersiniosis
Histoplasmosis - in the US

Question 20

what are some non-infective differential diagnosis of the bowel

Answer 20

Appendicitis
Diverticulitis
Diverticular colitis
Carcinoma
Ischaemic colitis
Lymphoma
Endometriosis
Carcinoid

Question 21

what is the managment of acute severe UC

Answer 21

admit
Toxic megacolon = surgical emergency
Early gastroenterology/colorectal surgery opinion

Do not delay steroids until stool cultures available; if necessary cover with antibiotics
Prednisolone 40mg od if less severe
Hydrocortisone 100mg tds-qds/ methylprednisolone 60-80mg/d

Stool chart
Daily AXR if initial dilatation or subsequent deterioration
Intravenous fluids
Blood prn
bloods
magnesium and cholesterol IFN gamma assay

Question 22

what is the managment of acute severe CD

Answer 22

Obstructive – inflammatory or fibrotic stricture?
If inflammatory, use steroids
Elemental/polymeric diet

Crohn’s colitis – treat as for UC
Perianal CD - metronidazole or ciprofloxacin for fistulae

Question 23

what is the treatment pyramid for IBD

Answer 23

aminoglycosides
corticosteroids
immuomodulators
surgery
and biologics throughout
more than 2 steroids a year - move up a step

Question 24

what are corticosteroids used for in IBD

Answer 24

Oral/topical
Active UC or CD

Orally acting topical steroids
Budesonide CR (Entocort/Budenofalk)
Budesonide MMX (Cortiment)
Beclometasone (Clipper)

Question 25

What are aminosalicylates used for in IBD

Answer 25

pH dependent release/resin coated (Asacol, Salofalk, or Ipocol, Mesren); time controlled release (Pentasa); delivery by carrier molecules, with release of 5-ASA after splitting by bacterial enzymes in the large intestine (sulphasalazine (Salazopyrin), olsalazine (Dipentum), balsalazide (Colazide)) MMX – Mezavant – multimatrix system – delayed release Topical therapy

Question 26

what are thiopurines used in IBD

Answer 26

Azathioprine/mercaptopurine Unlicensed! Induce T-cell apoptosis Effective for active disease and maintaining remission Slow onset of action Steroid sparing agents Blood tests

Question 27

what post op prophylaxis is needed for CD

Answer 27

Smoking Mesalazine Thiopurines Metronidazole 3/12 (Biologics)

Question 28

why do we check TPMT

Answer 28

you can poison 1 in 3 people

Question 29

what are the 2 main motilty symptoms

Answer 29

diarrhoea constipation

Question 30

how do you describe poo

Answer 30

bristol stool chart

Question 31

what is dysentery

Answer 31

diarrhoea with visible blood or mucus; commonly associated with fever and abdominal pain

Question 32

define acute, persistnet and chronic diarrhoea

Answer 32

Acute — 14 days or fewer in duration Persistent — more than 14 but fewer than 30 days in duration Chronic — more than 30 days in duration

Question 33

what causes diarhoea

Answer 33

reduced absorbsion of water out of the gut increased secretion of water into the gut

Question 34

what causes diarfhoea

Answer 34

usually infection or drug

Question 35

what is osmotic diarhoea

Answer 35

water is drawn into or retained in the bowel due to the presence of solutes within the lumen, typically due to: ingestion of a poorly absorbed solute malabsorption if you stop eating - diarrhoea stops

Question 36

what causes osmotic diarhoea

Answer 36

carbohydrate malabsorption - lactose intolerance magnesium-induced - heartburn and GORD osmotic laxatives - lactulose small intestinal mucosal disease - coeliac, crohns reduced absorptive area - surgery, radiation or coeliac bile acid malabsorption - facilitate fat absorbsion pancreatic exocrine insufficiency - chronic pancreatitis

Question 37

what causes secretory diarrhoea

Answer 37

bacterial endotoxins - C diff, cholera, E coli stimulant laxatives - senecot hormones - hyperthyroidism bile acid malabsorption mucosal inflammation - UC rectal villous adenoma

Question 38

how do you treat diarhoea

Answer 38

Treat underlying disorder Opiates decreased urgency, bowel frequency, stool volume codeine phosphate, loperamide Beware IBD, shigellosis Anti-secretory drugs Octreotide – somatostatin analogue

Question 39

what causes constipation

Answer 39

endocrine metabolic neurological neuromuscular psychological physiological mechanical

Question 40

what are the general treatments for constipation

Answer 40

identify anatomical abnormalities identify biochemical causes stop constipating drugs exercise increase fluid intake increase dietary fibre (SE - bloating, flatulence)

Question 41

what are bulk forming laxitives for and give 2 examples

Answer 41

mild constipation cannot increase dietary fibre improves bowel frequency rather than consistency/straining e.g.ispaghula, sterculia

Question 42

what are stimulant laxitives for and give 2 examples

Answer 42

chronic constipation increases motility, frequency, improves consistency minimise usage to decrease atonic colon e.g. bisacodyl, senna, sodium picosulphate

Question 43

what are stool softeners for and give example

Answer 43

Limited efficacy Widely used e.g. sodium docusate, liquid paraffin, arachis oil enema

Question 44

what are the 2 osmotic laxitives

Answer 44

lactulose and magnesium

Question 45

how does lactulose used

Answer 45

syrup derived from lactose decreases colonic pH by generation of fatty acids and fermentation products SE - bloating, flatulence