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Gastroeneterlogy Flashcards

1
Q

Define diarrhoea

A

Increased frequency due to increased water content of stools

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2
Q

Define steatorrhoea

A

Pale, yellow/white stools that do not easily flush due to increased fat content of stools.

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3
Q

Fecal urgency suggests ____ pathology

A

Rectal

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4
Q

Differential diagnosis for diarrhoea

A

Classify accoring to features and cause

A) Gastrointestinal causes

  1. Acute onset
    • Suspect gastroenteritis
  2. Chronic onset
    • Alternating with constipation - IBS
    • With wt loss, anorexia, nocturnal - think organic cause
  3. Blooody diarrhoea
    • Vascular - ischaemic colitis
    • Infective - CHEST + C.dif
    • Inflammatory - IBD
    • Neoplastic - polyps, CRC
  4. Mucus diarrhoea
    • Inflammatory - IBD
    • Neoplatic - Polyps, CRC
  5. Purulent diarrhoea
    • Diverticulitis, abscess

Other causes:

  1. Associated with disease
    • Hyperthyroidism
    • Autonomic neuropathy
    • Carcinoid
  2. iatrogenic - drug
    • PPIs, cimentidine
    • Abx
    • NSAIDs
    • Digoxin
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5
Q

General management of diarrhoea

A
  1. Treat the cause
  2. Oral or IV hydration
  3. Codeine phosphate or loperamide after each loose steal
  4. Abx if needed
  5. Anti-emetics if needed - prochlorperazine
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6
Q

Common infective causes of bloody diarrhoea

A

CHESS + pseudomembranous colitis

  • C - campylobater
  • H - haemorrhoagic E. Coli
  • S - salmonella
  • S - shigella
  • C. Diff
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7
Q

The C. Diff pathogen

A

Gram +ve spore forming anerobe

Produces enterotoxin A and B

Spores can survive for more than 40 days

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8
Q

Tha main causative organism of abx assocaited dirrhoea is ____ and acconunts for ____ % of cases

A

C. Diff.

25%

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9
Q

Tha main causative organism of psudomembranous collitis is ____ and acconunts for ____ % of cases

A

C. Diff

100%

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10
Q

Risk factors for C. Diff

A
  1. Antibiotic use - up to 2 months post use
  2. PPIs
  3. Prolonged hispital stay with c.diff contact
  4. increased age
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11
Q

Clinical presentation of C.Dif gastroeneterologicla infection

A

Disease spectrum

  1. Asymtomatic
  2. Diarrhoea
  3. Colitis withour pseudomebranes
  4. Pseudomembranous colitis
  5. Fulminant colitis
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12
Q

What is pseudomembranous colitis?

A

Inflammation of the colon secondary to C. Diff infection.

Presents as:

  • Systemic symtoms: fever and dehydration
  • Abdo pain, blood diarrhoea and mucus PR

Pseudomembranes (yellow plaques) are visualised on flexi sig

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13
Q

What are the complications of pseudomembranous colitis

A
  • toxic megacolon
  • Toxic dilataion with perforation
  • Multiorgan failure
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14
Q

Severe C.Dif infection would be classified as

A

Having one or more of the following:

  • WCC > 14
  • Cr >50% of baseline
  • Temp >38.5
  • Features of severecolitis clinically or radiologically
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15
Q

Management of C.Diff

A
  1. IV/PO hydration
  2. Avoid opioids/antidiarrhoeals
  3. Enteic precautions
  4. Stop abx
  5. Start abx:
    1. Metronidazole 400mg TDS PO for 10-14 days
    2. Second line or if very severe: Vancomycin 125mg QDS PO for 10-14 days
      • If no response, double dose. Double again to max (500mg) if still no reposne.
  6. Urgent coelctomy if: toxic megacolon, increasing LDH or deteriorating condition.
    7.
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16
Q

There is a ____% relapse following c.diff treatment. THis is further treated with?

A

15-30%

With a repeat course of metro 10-14 days.

Vanc if further relapses (25%)

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17
Q

Defintion of constipation

A

Constipation is defined as infrequent stool (3 or less a week) or a decrease from the norm, or associated with difficulty, straining or pain.

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18
Q

Causes of constipation

A

OPENED IT

  • O - obstruction
    • Mechanical -
      1. Luminal - cancer, adhesions, inflammatory stricutres
      2. Extraluminal - hernia, cancer, pelvic mass
    • Pseudo-obstruction - post op illeus
  • P - Pain in the Perineal area:
    • Proctalgia fugax
    • Anal fissures
  • E - endocrine and metabolic (electrolytes)
    • Low T4
    • Low Ca, low K, uraemia
  • N - neuro
    • MS
    • Cauda equina
    • Myelopathy
  • E - elderly
  • D - diet/dehydration
  • I - IBS
  • T - toxins - Opioids and anti-muscarinins
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19
Q

management of constipation

A
  1. Conservative:
    1. hydrate and dietary modification
    2. Tx the cause
  2. Medical:
    1. Laxatives:
      1. Oral, Enemas or Suppositories
      2. Types:
        1. Osmotic - when others have failed
        2. Bulk forming - take a few days to work
        3. Stimulants - 6-12 hours to act
        4. Softeners - for rectal/anal pain
  3. Surgical - manual evacuation - very rarely done.
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20
Q

Name three bulk-forming laxatives

A
  1. Fibogel (ispaghula husk)
  2. Bran
  3. Methylcellulose
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21
Q

Name three stimulant laxatives

A
  1. Senna
  2. Docusate sodium
  3. Bisacodyl (PO or PR)
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22
Q

Name three osmotic laxatives

A
  1. Movicol
  2. Lactulose
  3. MgSO4 for rapid action
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23
Q

Give an example of an enema and a suppository used in constipation

A

Enema: phosphate enema (osmotic)

Suppository: glycerol (stimulant)

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24
Q

Defintion of IBS

A

Irritable bowel syndrome is a disorder of enhanced viscerla perception. It is bowel symtoms without an identifiable organic cause.

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25
Q

Clincal features of IBS

A

IBS features are outlined in the ROME diagnositc criteria:

  1. abdominal pain or discomfort for at least 12 weeks with at least two of the following features (“IBS”):
    • Increased or decreased frequency
    • Better on passing stool
    • Shape or form changes: pellets, mucus…
  2. Additonally two of the following:
    • Mucus PR
    • Urgency
    • Bloating/distention
    • Incoplete evacuation
    • Worsening after food
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26
Q

Managment of IBS

A
  1. Conservative:
    • Dietary modification and trails of exclusion diets
  2. Medical:
    1. To treat symtoms:
      1. Bulking agents for constipation and diarrhoea: fybogel
      2. Antispasmodics for pain and bloating: mebevirine
    2. To treat IBS:
      1. Amitryptyline
      2. CBT
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27
Q

Causes of dysphagia

A
  1. Inflammation
    1. Apathous ulcers
    2. Oral candidiasis
    3. Tonsilits
    4. Pharyngitis
    5. Oesophagitis: GORD and candida
  2. Obstruction
    1. Luminal - FB or food bolus
    2. Mural
      1. Bening stricture
        1. Plummer-Vinson
        2. Oesophagitis
        3. Trauma
      2. Malignant stricture:Pharynx, oesophagus, gastric.
      3. Pharangeal pouch
    3. Extra-mural
      1. Lung cancer, mediastinal LNs
      2. Thoracic aortic aneurysm
      3. Substernal goitre
      4. Rolling hiatus hernia
  3. Motility
    1. Local:
      1. Pseudobulbular/bulbular palsy
      2. Achalasia
      3. Diffuse oesophageal spasm
      4. Nutcracker syndrom
    2. General: CREST/scleroderma, MG
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28
Q

Causes of dysphagia

Intial dyspahgia to solids, then liquids suggests?

A

Stricutre

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29
Q

Causes of dysphagia

Dyspahgia to solids AND liquids from the start suggests?

A

Motility disorder

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30
Q

Causes of dysphagia

Diffidulty making the swallowing motion suggests?

A

bulbar palsy

31
Q

Causes of dysphagia

odynophagia suggests?

A

Cancer, oesophageal ulcer, spasm

32
Q

Causes of dyphagia

Intermittent dysphagia suggests?

A

Oesophageal spasm

33
Q

Causes od dysphagia

Constant and worsening dyshagia suggests

A

Malignant stricture

34
Q

Causes of dysphagia

Neck bulging or gurgling on drinking suggests

A

Pharangeal pouch.

35
Q

Pathophysiology and causes of Achalasia

A

Degeneration of the myenteric plexus (Auberback’s) causing failure of relaxation of the LOS and decreased peristalsis

Causes:

  1. Idiopathic (majority)
  2. Secodnary:
    1. Chagas (t.Cruzzi)
    2. Oesophageal cancer
36
Q

Complicatipns of achalasia

A

SCC after chronic achalasia

37
Q

Investigations and findings in achalasia

A
  • Ba swallow - birds beak: dilated tappered oesophagus
  • manometry - failure of relaxation
  • CXR - widened mediastinum
  • OGD - exclude malignancy
38
Q

Management of achalasia

A
  1. Medically - CCB, nitrates
  2. Interventional - ballon dialtation, botulim toxin injection
  3. Surgical - Heller’s cardiomyotomy (open or endo)
39
Q

What is a pharangeal pouch

A

Outpouching of the pharangeal wall at Killian’s dehiscence, an area of wekeness between the cricopharangeal musle and the inferior constrictor of the pharynx

40
Q

Presentation of a Pharangeal pouch

A

Dysphasia, regurgitation, halitosis and gurgling noises

41
Q

Management of a pharangeal pochh

A

Ecision and edoscopic stapling.

42
Q

Ba swallow finding in diffuse oesophageal dismotility

A

Corckscrew appearance

43
Q

What is nutcrackers oesophagus

A

A form of motility disorder causing dysphagia and caused by increased contraction pressure with normal peristalsis. “Hypertensive peristalsis”.

44
Q

What is dyspepsia?

A

A non-specific group of symtoms incuding epigastric pain, heartburn and bloating.

45
Q

How do you manage a patient with dyspepsia

A
  1. OGD if over 55 or has ALARM Symtoms (anaemia, loss of weight, anorexia, recent onset with progressive symtoms or melena/heamatemesis, swallowing difficulty)
  2. Otherwise:
    1. STEP 1 - 4 week trial of conservative management
      • Weight loss, smoking cessation, decrease alcohol, avoid spicy food and hot drinks
      • Stop drugs: CCBs and NSAIDs
      • Antacids (magnesium tricilicate) or alignates (gaviscon)
    2. If no improvement: test for H.Pylori
      1. Positive? iradication therapy
      2. Negative? PPI trial for 4 weeks.
    3. Still no improvement? OGD
      1. Proven GORD - high dose PPIs for 1-2 months, then PRN.
      2. Proven PUD - high dose PPIs for 1-2 months, endoscopy to check clearance, then PPIs PRN
      3. Otherwise, likely functional: non-ulcer dyspepsia.
46
Q

Eradication therapy

A

7 days treatment of either:

  1. PAC 500
    • PPI - lansoprazole 30mg BD
    • Amoxicillin 1g BD
    • Clarythromycin 500mg BD
  2. PMC 250
    • PPI - Lansoprazole 30mg BD
    • Metronidazole 400mg BD
    • Clarythromycin 250mg BD
47
Q

False negative C13 breath tests and antigen tests for H. pyloi are seen with?

A

PPIs and cimentidine - stop 2 weeks before test.

48
Q

Failure rate, cause and solution in eradication therapy

A

5% failure, mainly due to poor complaince. Can add bisthmus. SE stools tarry black.

49
Q

Causes of peptic ulder disease

A
  1. Acute: drugs (NSAIDs, steoirds), “stress”
  2. Chronic: drugs, high calcium, Zollinger Ellison, H. Pylori
50
Q

Risk factors of Peptic ulcer disease

A
  • Both:
    • H.Pylori (90% DU, 80% GU)
    • Smoking
    • Drugs (NSAIDs and steroids)
  • DU -
    • Increased gastric empyting
    • EtOH
    • Blood group O
  • GU -
    • Delayed gastric empyting
    • Stress: cushing - intracranial disease, curling - stress, trauma, burns.
51
Q

Common locations for ulcers

A

Most commony: Duodenal - 1st segment

Gastric - lesser vurvature of the gastric antrrum, anywhere else and suspect malignancy,

52
Q

Complications of PUD

A
  1. Haemorrhage (melena/haemoptysis and Fe deficiency anaemia)
  2. Perforation
  3. Gastric outflow obstruction
  4. Malignancy - particulary with H.Pylori
53
Q

Management of PUD

A
  1. Conservative:
    1. weight loss, smoking cessation, alcohol reduction, avoidance of spicy food and hot drinks
    2. Stop drugs: NSAIDs and steods
    3. OTC antacids: Mg Tricilicate and gaviscon
  2. Medical:
    1. OTC antacids
    2. H. Pylori irradicarion (PAC500, PMC250)
    3. PPI 1-2 month high dose (lasnorazole 30mg OD/ ranitidine 300mg nocte)
    4. Follow uo with low dose PRN acid supression
  3. Surgery:
    1. Vagotomy
      1. Truncal (add pyloroplasty or gastroenterostomy)
      2. Selective
    2. Anterectomy with vagotomy
    3. Subtotal gastrectomy with Roux-en-Y
54
Q

Pathophysiology of GORD

A

LOS dysfunction resulting reflux of the gastric contents an dsubsequent oesophagitis.

55
Q

Risk factors for GORD

A

Decreased LOS tone:

  1. Hiatus hernia
  2. iatrogenic - hellers myomotomy
  3. Drugs: CCB, nitrates, TCA’s, anti-AChM

Increase abdo pressure

  1. Obesity
  2. Pregnancy

Other:

  1. EtOH
  2. Smoking
56
Q

Symtoms of GORD

A
  1. oesophageal
    • Heart burn
    • restrosternal chest pain
    • Belching
    • Odynophagia
  2. Extra-oesophageal
    • Sinusitis, laryngitis
    • Chornic cough
    • Nocturnal asthma
57
Q

Complications of GORD

A
  1. Ulceration - heamoptysis, melena, low Fe
  2. Benign strictures
  3. Barrets esophagus
  4. Adenocarcinoma of the oesophagus
58
Q

Investigations for GORD

A
  • Isolated symtoms do not need investigation.
  • OGD if:
    • ALARM Symptoms (anorexia, weight loss, anaemia, recent onset with progression, melena/haemoptysis, Swallowing difficulties
    • >55
    • >4 weeks duration of symptoms
  • 24h Ph testing (4hours) and manometry
  • Barium swallow - hiatus hernia/dysmotility.
59
Q

Manageent of GORD

A
  1. Conservative
    • weight loss, smoking and EtOH reduction, aoidance of spicy food and hot beverages, meals more than 3 hours pre bed
    • Stop drugs: CCB, nitrates, NSAIDs, anti muscarnics, TCAs, steroids
  2. Medical
    • Antacids and alginate: Mg. tricilicate and gaviscon
    1. If comfirmed GORD - 1-2months full dose PPIs (30mg OD lansoprazole)
    2. No repsonse? double to BD.
    3. No response? Add ranitideine 300mg nocte.
    4. control PRN with low dose.
  3. Surgical
    • Nissen’s fundoplication
60
Q

Indications for Nissen’s fundoplicaton in the management of GORD

A
  1. Severe symtoms
  2. Refractory to medical therapy
  3. Comfirmed reflux (on pH monitoring)
61
Q

Investigations in hiatus hernias. Diagnostic and otherwise

A
  • CXR
  • Ba swallow: diagnostis
  • OGD - visualize mucosa but canno exclude henria
  • pH 24 hours + manometry
62
Q

Management of hernias

A
  • Weight loss
  • Treat reflux
  • Surgical if intractable symtoms or rolling hernia (even if asymtomatci as it may strnagulate).
63
Q

Barium follow through/enema features of Crohn’s versus UC

A

Crohn’s

  1. Skip lesions
  2. Rose thorn ulcers
  3. Cobblestoning
  4. String sign of cantor

UC

  1. Lead pipping
  2. Thumbrinting
  3. Pseudopolys
  4. Procto>colo>illeum
64
Q

Management of a severe attack of UC

A
  1. Resus
  2. IV + PR hydrocortisone
  3. LMWH
  4. (Transfusion if requires)

Twice daily monitoring.

Switch to oral Pred (40mg/d) when there is improvement.

65
Q

Management of an acute severe attack of Crohn’s

A
  1. Resus
  2. IV (+/- PR) hydrocortisone
  3. LMWH
  4. Metronidazole PO or IV
  5. Dietician review

Daily examination

Switch to oral Pred (40mg/d) when there is improvement.

66
Q

Management of mild/moderate relapse of UC

A
  • 1st line- 5-ASA
  • 2nd line - prednisolone

Other: azathithioprine or infliximab (in steroid dependant patients)

67
Q

Management of mild/moderate relapses of Crohns

A
  • First line - Illeocaecal - budenoside; rectal - sulfasalazine
  • Second line - prednisolone
  • Third line - methotrexate
  • Fourth line - infliximab
68
Q

Maintaining remission in UC

A
  • 1s line - 5-ASA (sulfasalazine, mesalazine)
  • 2nd line - azathioprine, 6-mercaptopurine

(If relapse of 5-ASA or steroid dependant)

  • 3rd line - infliximab
69
Q

Maintaining remission of Crohns and other long term management

A
  • First line - Azatioprine or mercaptopurine
  • Second line - Methotrexate
  • Third line - Infliximab

High fibre diets and vitamin suppelment.

70
Q

Extra-abdominal features of IBD

A
  1. Skin - erythema nodosum, pyoderma gangrenosum, clubbing
  2. Eyes - uveitis, conjunctivitis, episcleritis
  3. Joints - arthitis (non-deforming, assymetricc, sacroillitis, ank spond)
  4. HPB - primary billiary cirrhosis + cholangiocarcinoma (UC mainly), Gallstones (crohn’s ainly), fatty liver
  5. Other - amyoidosis, oxalate renal stones
71
Q

Distinguishing features of UC and Crohn’s on endoscopy

A

3 macroscopic and 3 microscopic differences.

Macroscopically

  1. Location:
    • UC - recturm, proximally
    • Crohns - mouth to anus
  2. Distribution
    1. UC - contiguous
    2. Crohn’s - skip lesions
  3. Strictures - UC no, Crohn’s yes

Microscopically

  1. Infammation
    1. UC - mucosal, crypt abscesses
    2. Crohn’s - transmural
  2. Ulceration
    1. UC Shallow and broad
    2. Crohn’s - deep thin, serpiginous (cobblestoning)
  3. Extra features:
    1. UC - marked psudopolyps
    2. Crohn’s - Fistula, granulomas, fibrosis
72
Q

UC has a concordance of ___% and is ___ mediated. Smoking is ____

Crohn’s has a concordance of __% and is__ mediated.

Smoking is ___

A

UC has a concordance of 10% and is Th2 mediated. Smoking is protective

Crohn’s has a concordance of 70% and is Th1 and Th17 mediated.

Smoking is a risk factor.

73
Q

Complications of UC and Crohns

A

Both: stricture

UC

  1. Malignancy (more than Crohns) - cholangiocarcinoma and colonic.
  2. Heamorrhaging
  3. Toxic megacolon (more than crohns)
  4. Perforation

Crohn’s

  1. Fistula
  2. Abscess
  3. Strictures - obstruction
  4. Malabsorbtion - fat, B12, vit D, protien.

Medicine (6 decks)

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