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Human Diseases Yr4 > Gastroenterology > Flashcards

Gastroenterology Flashcards

1
Q

What is gastro-oesophageal reflux disease (GORD)?

A

Retrograde flow of gastric contents into oesophagus. Rarely life threatening but frequently chronic and affects QOL, heart pain and can induce premalignant change in esophagus.

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2
Q

What is the anti-reflux barrier?

A

Lower oesophageal sphincter (LOS) has transient changes in pressure - GORD have lower LOS pressures on average
Diaphragm acts as external sphincter

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3
Q

What is in the refluxed material?

A

Acid and pepsin

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4
Q

What are the oesophageal defence mechanisms?

A
  • Oesophageal clearance = gravity and peristalsis (?peristaltic dysfunction or hiatus hernia if oesophageal clearance impaired)
  • Saliva contains bicarbonate to neutralise acid
  • Oesophageal mucosa = mucous, bicarbonate and prostaglandins are protective
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5
Q

What are the risk factors for GORD?

A
  • Pregnancy (pressure against diaphragm)
  • Hiatus hernia
  • Genetic
  • Smokers
  • Obesity
  • Large meals late at night
  • High fat content
  • Excess alcohol or caffeine
  • Drugs e.g. TCAs, anticholinergics, nitrates, Ca blockers
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6
Q

What are the symptoms of GORD?

A
  • Heartburn related to meals, lying down, relieved by antacids
  • Retrosternal discomfort
  • Acid brash - regurgitation acid or bile
  • Water brash - excessive salivation
  • Odynophagia - pain on swallowing due to sever oesophagitis or stricture
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7
Q

What are the atypical symptoms of GORD?

A

Non-cardiac chest pains
Dental erosions
Respiratory symptoms: asthmatic symptoms ie wheeze, laryngitis, chronic cough, chronic hoarseness
Episodic or chronic aspiration can cause pneumonia, lung abscess and interstitial pulmonary fibrosis

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8
Q

In GORD, what symptoms are alarm symptoms and should be referred immediately?

A
  • Acute GI bleed
  • Dyspepsia (indigestion) with:
    a) chronic GI bleed
    b) Progressive unintentional weight loss
    c) Progressive difficulty swallowing
    d) Persistent vomiting
    e) Iron deficiency anaemia
    f) Epigastric mass
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9
Q

What is the management of GORD?

A
  • Drug tx with PPI omeprazole

- Lose weight

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10
Q

What are the causes of upper GI bleeding?

A
  • Peptic ulcer disease
  • Duodenitis
  • Gastritis
  • Varix rupture (varicose veins rupture lower oesophagus)
  • Oesophagitis
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11
Q

What are the signs and symptoms of upper GI bleeding?

A
  • General abdominal discomfort
  • Haematemesis (vomiting of blood)
  • Malaena (blood rectally)
  • Shock (from loss of blood)
  • Changes in orthostatic vital signs
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12
Q

What are the causes of oesphageal varices (where varicose veins at lower end of oesophagus get larger and burst)?

A

Portal hypertension:

  • Chronic alcohol abuse and liver cirrhosis
  • Ingestion of caustic substances
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13
Q

What is the pathophysiology of peptic ulcers?

A

Erosions caused by gastric acid. Defect in the gastric or duodenal wall that extends through the muscularis mucosae into deeper layers of wall (submucosa or muscularis). Can erode through major blood vessels causing haemorrhage

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14
Q

What are the causes of peptic ulcers?

A 
Drugs - NSAIDs, corticosteroid use 
Alcohol/tobacco use 
H.pylori 
Stress
Changes in gastric mucin consistency (may be genetically determined
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15
Q

What are the signs and symptoms of peptic ulcers?

A

Abdominal pain

Haematemesis and melaena if haemorrhagic rupture

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16
Q

What is the treatment of peptic ulcers?

A

Surgery only if haemorrhage or perforation.
Must reduce acid secretion, neutralise the acid secretion and protect mucosa

Consider histamine blockers (H2 receptor antagonists), prostaglandin analogues, antacids, PPIs, chelates, antibiotics

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17
Q

What are the signs and symptoms of Crohns disease?

A 
Diarrhoea 
GI bleeding 
Nausea/vomiting 
Abdominal pain/cramping - intestinal obstruction and acute inflammation (appendicitis like)
Fever
Weight loss
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18
Q

What are the oral signs and symptoms of Chrohns disease?

A

Cobblestone mucosa
Granulomatous lesions (swollen lower lip, angular cheilitis)
Generalised inflammation
Recurrent aphthous stomatitis

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19
Q

Where do apthous ulcers most commonly present?

A

Inside of lips, cheeks, on tongue, on base of gums

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20
Q

Does ulcerative colitis have any oral manifestations

A

No - but secondary to iron deficiency anaemia

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21
Q

What conditions can cause apthous-like ulcers?

A
  • Immune system disorders
  • Blood diseases e.g. HIV
  • Vitamin deficiencies
  • Hormonal e.g. menstrual
  • Allergies
  • Stress
  • Trauma
  • GIT problems e.g. Crohns, coeliac disease
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22
Q

What is the treatment for oesophageal varices?

A

Propanalol to lower BP

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23
Q

What diseases make up inflammatory bowel disease?

A

Ulcerative colitis = muscosal ulceration in colon

Crohns disease = transmural inflammation in anypart of GI tract

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24
Q

Why is IBS different to IBD?

A

It is a diagnosis of exclusion

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25
Q

What is the age and sex incidence of inflammatory bowel disease?

A 
Tends to affect younger people 
Familial pattern (10-25% concordance) but genetic and environmental factors still unresolved
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26
Q

What are the drug groups used in inflammatory bowel disease?

A
  • Symptomatic agents e.g. antispasmodics
  • 5-ASA compounds (based on aspirin to reduce inflammation) e.g. sulfasalazine
  • Corticoids
  • Immunosuppressive
  • Antibiotics e.g. metronidazole (against anaerobic)
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27
Q

What is a fistula?

A

Pathological tract between 2 surfaces and lined with epithelium

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28
Q

What does a barium contrast study show?

A

Obstructions - black areas = strictures which can lead to infarction of the bowel

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29
Q

What can transmural inflammation develop?

A

Fistulae

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30
Q

What are the types of fistulae that can be present in the GI tract?

A
  • Mesenteric
  • Entero-enteric
  • Entero-vesical (bowel and bladder)
  • Retroperitoneal
  • Entero-cutaneous (bowel and skin e.g. through surgical scar or umbilicus)
  • Perianal
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31
Q

What are the systemic complications of IBD?

A
  • Aphthous stomatitis
  • Episcleritis (red eye) and uveitis (uneven pupil)
  • Arthritis - peripheral large joints, monoarticular - central ankylosing spondylitis and sacroiliitis (base of spine)
  • Vascular complications
  • E.nodosum causing painful skin rash
  • P.gangrenosum on outside of ankle
  • Gallstones
  • Malabsorption
  • Renal stones, fistulae, hydronephrosis, amyloidosis (deposits beta pleated sheets)
  • Bleeding with bowel movements - can lead to iron deficiency anaemia (hypochromic, microcytic)
  • Malignancy ie colorectal cancer in ulcerative colitis
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32
Q

What two diseases is granulomas seen in and is tested with serum angiotensin converting enzyme to differentiate?

A

Crohns

Sarcoidosis

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33
Q

What is proctocolitis and which patients is it seen in?

A

Inflammation of the colon

  • Ulcerative colitis
  • Crohns
  • Radiation pts
  • Ischaemia
  • Infections with C.diff
  • From antibiotics
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34
Q

What is a complication of non-universal ulcerative colitis?

A

Toxic dilatation/megacolon - can perforate leading to air in abdominal cavity, sepsis and multiorgan failure

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35
Q

What are the indications for surgery in non-universal ulcerative colitis?

A
  • Exsanguinating haemorrhage (pt will bleed to death)
  • Growth retardation
  • Systemic complications
  • Toxicity and/or perforation
  • Suspected cancer
  • Significant dysplasia (pre-cancerous)
  • Intractability
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36
Q

What is the management of non-universal ulcerative colitis?

A

Medical

Colonectomy will cure condition

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37
Q

What are the features of a peptic duodenal ulcer?

A
  • Intermittent epigastric pain usually post-prandial (1-3hrs post food)
  • Posterior ulcer may radiate pain to back
  • Haemorrhage - more rapid bleeding = melena (blleding rectal), slower = anaemia.
  • H.Pylori in 90%
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38
Q

What are the features of benign peptic gastric ulcer?

A
  • Intermittent epigastric pain
  • Chronic
  • Can perforate
  • H.Pylori in 60%
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39
Q

If a benign peptic gastric ulcer has perforated, what is seen on a chest xray?

A

Gas under right hemidiaphragm - surgical emergency as free gas in abdominal cavity. (left air normal as this is gastric bubble)

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40
Q

What 3 things are ulcer producing?

What 3 things are protective against ulcers?

A

Gastric acid, pepsin, H.pylori infection

Prostaglandins, mucus, HCO3-

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41
Q

How do H2 receptor antagonists work in the management of peptic ulcers? Give examples of drugs

A

Block histamine receptors to reduce gastric acid output

Cimetidine (most popular), Famotidine, Nizatidine, Ranitidine (can be used in hospital)

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42
Q

How do prostaglandin analogues work in the management of peptic ulcers? What drug is most used?

A

Inhibit gastric acid secretion. PGE2 and PGI2 stimulate mucus and bicarbonate
Inhibit adenylcyclase to reduce cAMP production
Misoprostol (PGE2 analogue)

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43
Q

How do proton pump inhibitors (PPIs) work in the management of peptic ulcers? Give examples of drugs EXAM Q!!

A

Final step in acid production is action of H+/K+ ATPase (proton pump). PPIs act to inhibit this enzyme. THey are pro-drugs and are activated in an acidic environment

Omeprazole 
Lansoprazole 
Esomeprazole 
Pantoprazole 
Rabeprazole
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44
Q

How do antacids work in the management of peptic ulcers? What drug is most used?

A

Weak bases that interact with gastric acid to produce salts. Raise the gastric pH which inactivates pepsin. Magnesium hydroxide, aluminium hydroxide

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45
Q

What are the side effects of magnesium salts? Aluminium salts?

A

Diarrhoea

Constipation

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46
Q

How do chelates and complexes work in the management of peptic ulcers? Give drug examples

A

Protect the gastric and duodenal mucosa by coating mucosa. Stimulate bicarbonate and mucous secretion. Inhibit action of pepsin.

Bismuth chelate
Sucralfate (aluminium hydroxide and sulphated sucrose)

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47
Q

How is the presence of H.Pylori in peptic ulcers confirmed?

A

Blood, breath, stool, biopsy

48
Q

How is H.pylori eliminated in peptic ulcers

A

Triple therapy for 1 week:

  • PPI
  • Clarithromycin
  • Metronidazole or amoxicillin
49
Q

What are the drug interactions of sucralfate (chelate)?

A

Reduces effects of warfarin

Inhibits absorption of teracycline, ketoconazole and amphotericin

50
Q

What are the drug interactions of antacids?

A

Reduced absorption of tetracycline

51
Q

What are the drug interactions of omeprazole (PPI)?

A

Inhibits metabolism of diazepam
Inhibits absorption of ketoconazole and itraconazole
Increases effects of warfarin

52
Q

What are the drug interactions of Cimetidine (H2 receptor antagonist)?

A

Inhibits absorption of ketoconazole and itraconazole

Inhibits metabolism of anticoagulants, erythromycin, carbamazepine, metronidazole, benzodiazepines and bupivacaine

53
Q

What are the adverse reactions to Ranitidine (H2 receptor antagonist)?

A

Erythema multiforme and staining of tongue

54
Q

What are the adverse reactions to Sucralfate (chelate)?

A

Xerostomia and metallic taste

55
Q

What are the adverse reactions to H2 receptor antagonists?

A

Pain and swelling of salivary glands

56
Q

What is a side effect of omeprazole?

A

Dry mouth

57
Q

What peptic ulcer drug leaves a chalky taste in the mouth?

A

Antacids

58
Q

What are the systemic causes of dysphagia?

A
  • Myasthenia Gravis
  • Psychological
  • Muscle weakness
  • Multiple sclerosis
  • Parkinsons
  • Pseudobulbar palsy (upper motor neurone lesion)
59
Q

What investigations can be carried out for the oesophagus?

A
  • Oesophagoscopy (OGD)
  • Barium swallow (show where strictures are, details of motion)
  • CT scan (stages of cancer)
  • Oesophageal pressure monitoring
  • 24hr pH monitoring (reflux)
60
Q

What other therapeutic options does an OGD offer?

A

Dilation, stenting, removal of bolus obstruction, sclerotherapy (for GI bleeds)

61
Q

What investigations can be carried out for the stomach?

A
  • Gastroscopy (direct vision and biopsy)
  • CT scan
  • Barium meal (used less)
62
Q

What investigations can be carried out for the duodenum?

A
  • OGD gastro-duodenoscopy
  • Limited view of jejunum - jejunal biopsy (coeliac disease)
  • CT for adjacent and associated structures
63
Q

What are symptoms of small bowel disorders?

A

Pain/colic - comes in waves
Malabsorption - fatigue and systemic illness
Bleeding
Vomiting

64
Q

What tumour of the small bowel is very rare?

A

Carcinoid tumour - originates from endocrine cells - flushing oedema and abdominal cramping

65
Q

The jejunum and ileum are difficult to investigate - what investigations have some value?

A
  • CT scan
  • Special isotope scans - labels RVCs so can see bleeding
  • Angiography - can be helpful in GI haemorrhage
66
Q

What is diverticulitis?

A

Outpouching of large bowel becomes inflamed - associated with lower left quadrant pain

67
Q

What investigations can be carried out for the large bowel?

A

Colonoscopy/ flexible sigmoidoscopy - for biospy, polypectomy, stenting, laser treatment
Barium enema

68
Q

What investigations can be carried out for ano-rectal?

A 
Direct vision 
Digital examination 
Proctoscopy/rigid sigmoidoscopy 
Flexible sigmoidoscopy (for higher up) 
Examination under anaestethic 
Complex radiological assessments e.g. pelvic CT or transrectal ultrasound
69
Q

What is normal bowel habit?

A

Bowel movement between 3x day and once every 3 days

70
Q

What medications commonly cause indigestion?

A

Aspirin
Bisphosphonates
NSAIDs

71
Q

What are the indications for a colonoscopy?

A

Change of bowel habit
Bleeding
Surveillance in ulcerative colitis or polyposis
Diagnosis of non cancerous colonic conditions e.g. Crohns
Screening

72
Q

What conditions can affect the ano-rectal part of GI system?

A 
IBD e.g. ulcerative colitis 
Carcinoma of rectum 
Haemorrhoids 
Fissure 
Fistula (tract from bowel to skin often in Crohns)
73
Q

Why is a hiatus hernia important if the patient has an anaesthetic?

A

Causes acid reflux

Can result in acid ‘spill over’ under GA - risk of aspiration pneumonia

74
Q

What are the common causes of rectal bleeding?

A 
Haemorrhoids 
Anal fissure
Diverticular disease 
Cancer 
Collitis (infective and inflammatory) 
Vascular malformation
75
Q

What can a sigmoidoscopy view?

A

Lower third of colon up through rectum

76
Q

Where is the gallbladder positioned? What is its role?

A

At head of pancreas in groove of duodenum then extends across left abdomen where tail sits in spleen behind stomach.
Stores bile in between meals

77
Q

What are the 3 benign hepatico-pancreatic biliary (HPB) diseases?

A

Biliary obstruction e.g. stone disease (choledocholithiasis), strictures
Pacreatitis
Gallbladder disease e.g. gallstones

78
Q

What are the 3 malignant HPB diseases?

A

Liver tumpurs- hepatocellular carcinoma, intrahepatic cholangiocarcinoma, metastatic disease
Biliary tumours - cholangiocarcinoma
Pancreatic tumours - pancreatic ductal adenocarcinoma, periampullary tumours

79
Q

How does biliary disease present?

A

Pain - epigastric or right upper quadrant of abdomen, may radiate into back
Jaundice - yellowing skin/sclera, intractable itch
Nausea/vomiting
Weight loss
Pancreatic exocrine insufficiency - pale greasy stool, excessive flatulence
Poor diabetic control

80
Q

What are the causes of acute pain and chronic pain in biliary disease?

A 
Acute = gallstones, pancreatitis 
Chronic = malignancy or chronic pancreatitis
81
Q

What type of stones are predominant in gallstone disease?

A 
Cholesterol stone (bile saturated with cholesterol) 
Pigment stones rare in west
82
Q

What is biliary colic? What is the treatment?

A

Pain typically after eating and self limiting over 30mins-2hrs
No systemic upset
Tx: cholecystectomy, non emergency, surgery to remove gallbladder

83
Q

What is acute cholecystitis? What is the treatment?

A

Pain typically after eating not self limiting
Associated with fever
Stone in neck of gallbladder, distention gallbladder, inflamed and ischaemic
Treatment with antibiotics and emergency cholecystectomy

84
Q

What is obstructive jaundice?

A

Painful - typically associated with stones in the bile duct

Painless - biliary strictures or malignancy

85
Q

How is obstructive jaundice differentiated from non-obstructive jaundice?

A
  • History
  • LFTs - increased alkaline phosphatase, gamma GT, increased ALT
  • Biliary dilation on imaging by ultrasound
86
Q

What is ascending cholangitis?

A

Medical emergency - charcot’s traid of fever pain and jaundice due to infection in obstructed bile duct. Will need urgent biliary decompression, antibiotic therapy and resuscitation

87
Q

Why do patients with obstructive jaundice have abnormal coagulation?

A

Bile essential for fat absorption, vit K absorbed with fat - essential for clotting factors. Prolonged prothrombin time

88
Q

What is endoscopic retrograde cholangio-pancreatography (ERCP)?
What is used for?
What are the risks?

A

Endoscopic procedure with access to biliary tree via ampulla of vater. (if obstruction below hylem then down oropharynx into stomach)
Uses: clear gallstones, stent strictures
Risks: pancreatitis, bleeding, perforation of duodenum

89
Q

What is percutaneous transhepatic cholangiography?
What is it useful for?
What are the main risks?

A

Percutaneous radiological procedure under ultrasound guidance
Uses: for failed ERCP or more proximal biliary obstruction
Risks: Bile leak, bleeding, pancreatitis (rare)

90
Q

What is required for diagnosis of acute pancreatitis?

A

1) Hyperamylasaemia - exocrine enzymes of pancreas increased in blood
2) Appropriate symptoms - upper abdo pain into back
3) Appropriate imaging

91
Q

What is the aetiology of pancreatitis?

A 
Gallstones (50%) 
Alcohol (25%) 
Drugs e.g. steroid, methotrexate, azathioprine, sodium valporate 
Hyperlipidaemia 
Autoimmune (IgG4)
Hypercalcaemia
92
Q

What is severe acute pancreatitis defined as?

A

Multiorgan failure persisting more than 48 hours or the development of late complications which may require intervention (>4weeks) e.g. pancreatic necrosis

93
Q

What is the management of

a) mild acute pancreatitis?
b) severe acute pancreatitis?

A

a) fluids, pain control, remove cause e.g. gallstones within 2 weeks
b) organ, nutritional support and intensive care. Manage complication and underlying cause

94
Q

What can be seen on a CT scan in pancreatitis?

A

Autodigestion and necrosis. Gas and fluid in retroperitoneum

95
Q

What is chronic pancreatitis?

A

Chronic inflammatory process characterised by gland fibrosis with loss of parenchymal function and development to strictures within pancreatic duct

96
Q

What are the clinical features of chronic pancreatitis?

A

Pain, exocrine insufficiency e.g. pale greasy stool, endocrine insufficiency e.g. diabetes, jaundice

97
Q

What are the causes of chronic pancreatitis?

A
  • Alcohol
  • Recurrent acute inflammation
  • Autoimmune
  • Tropical (India)
  • Genetic e.g. CFTR (cystic fibrosis)
98
Q

What thing in a patients history may you think indicates cancer and you must signpost for?

A
  • Dysphagia
99
Q

If a patient is predisposed to gastritis but you need to prescribe an NSAID, what should you prescribe alongside it?

A

PPI e.g. omeprazole

100
Q

On examination, if a patient has finger clubbing what GI disorders may be the cause?

A

GI lymphoma, inflammatory disorder e.g. Crohns

101
Q

On examination, what are these two signs that are indicative of GI disorders? Ascites and scaphoid abdomen

A 
Ascites = intraabdominal free fluid, enlarged abdomen and slushing sounds 
Scaphoid = hollowed out, concave
102
Q

In malnutrition, why is the abdomen swollen?

A

Loss of protein from intravascular compartment, changes oncotic pressure so fluid moves extravascular

103
Q

If a patient presents with Jaundice, what would you expect to find in their history?

A

Drug/alcohol - erythromycin can predispose jaundice, cirrhosis from alcohol abuse
Bleeding problems (affects vit K clotting factors 7 9 10)
History blood transfusion
History foreign travel - place where jaundice endemic and no vax
History sexual promiscuity i.e. hepatitis
Pale stool/dark urine - obstructive jaundice

104
Q

What are the physical signs of jaundice?

A 
Yellowed sclera
Scratch marks 
Liver flap/asterixis (ammonium based compounds not detoxified can affect NS)
Nail beds (leukonikia -white nail) 
Spontaneous haemorrhage (bruising) 
Gynaecomastia (lack of oestrogen metabolism) 
Palmar erythema
Ascites
105
Q

What investigations can be done for a patient presenting with jaundice?

A

Stool/urine analysis
Blood tests (LFTs):
- AST and ALT - if raised then liver cells depleted
- gamma glutamyl transferase - for alcohol
- FBCs for macrocytic anaemias
Abdominal US
CT is possibility of cancer

106
Q

When pain is due to inflammation e.g. appendicitis, peritonitis, when is:

a) Pain poorly localised in initial stages
b) Well localised when it spreads

A

a) sympathetic nervous system hard to tell which organ

b) supplied by somatic nerves

107
Q

What is the pain like when a patient has an obstruction?

A

Comes in waves (apart from biliary colic which is constant)

108
Q

What signs/symptoms are indicative of peritonitis?

A

Pain felt in area of inflammation, pain worse with movement, coughing, inspiration
Guarding/rigidity
Rebound tenderness - pain worse on withdrawal of hand
Percussion tenderness
Absent bowel sounds

109
Q

What are the immediate investigations when someone presents with abdominal pain?

A

Urine testing - infection, trauma, pregnancy
FBCs - increased if appendicitis
U+E - kidney function
Amylase - pancreatitis
Pain x rays - erect CXRm supine AXR - can show obstructions or perforations

110
Q

What is a laparoscopy? What is laparotomy?

A

Keyhole surgery in abdomen - CO2 in abdominal cavity to lift to see structures - if laparoscopic appendicectomy then removed

Open surgery with vertical midline scar

111
Q

What is appendicitis caused by? What are its presenting symptoms?

A

Obstruction of lumen by faecolith (calcified faeces), inflammation of localised lymph tissue, carcinoma

Initial central colicky pain then localised to right iliac fossa, mild temperature, increased WBCs

112
Q

What is mesenteric adenitis?

A

Enlargement of mesenteric lymph nodes in children/adolescents - often confused with appendicitis and associated with URTI, earache, sorethroat, high temp, tenderness and raised WBCs

113
Q

What are the symptoms for a perforated peptic ulcer?

A

Sudden onset of pain in upper abdomen, central abdomen or upper left Q.
History of ulcers, reflux or heartburn
Rigid silent abdomen - generalised peritonitis
Absence of bowel signs

114
Q

What is diverticular disease?

A

Large bowel develops pouches on sides of abdominal wall - usually left side of colon. From poor diet without fibre.

115
Q

What are the 4 cardinal features of intestinal obstruction?

A

Pain, distension, vomiting, absolute constipation

116
Q

If an older male C/O severe abdominal pain radiating into back or groin with a pulsatile mass in abdomen, what is the cause?

A

Ruptured aortic aneurysm (dilation of aorta >3cm) - fatal if untreated

Human Diseases Yr4 (10 decks)

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