Gastroenterology Flashcards
Crohn’s Disease
- Pathophysiology
- Presentation
- Investigation
- Management
- Complications
Pathophysiology
- Skip lesions (normally terminal ileum/colon) w/ transmural inflammation –> strictures, fistula, adhesions
- Cobblestone appearance
- Non-caseating granulmatous infection, goblet cells
Presentation
- late teens
- weight loss, lethargy, diarrhoea, abdo pain, perianal skin tags/ulcers, oral aphthous ulcers
- Crohn’s colitis -> bloody diarrhoea
- Extra-intestinal features:
Related to disease activity: arthritis, erythema nodosum, episcleritis, osteoporosis
Unrelated to disease activity -> arthritis, uveitis, pyoderma gangrenosum, clubbing
Investigations
- Faecal calprotectin - used to confirm acute flare
- Colonoscopy w/ biopsies
- can be low vit B12 (terminal ileum) +Vit D
Management
- Stop smoking
- Inducing remission (flares):
Generally:
- 1st line: steroids OR elemental diet (eg. in children if worry re SE of steroids)
- 2nd line: 5-ASA (e.g. mesalazine)
- + azathioprine, mercaptopurine or methotrexate (add ons, not used as monotherapy)
Refractory/fistulating:
- infliximab
Isolated peri-anal disease:
- metronidazole
Maintaining remission
- Stop smoking
- 1st line Azathioprine or mercaptopurine
- (check TPMT activity before starting)
- 2nd: methotrexate
Surgery:
- Stricturing terminal ileal disease -> ileocaecal resection
- Segmental small bowel resection
- Stricturoplast
- Perianal fistulae: MRI to Ix. If syptomatic - PO metronidazole +/- anti-TNF (infliximab), draining seton
- Perianal abscess (incision + drainage + abx therapy)
Complications
- Fistulae, fissures, strictures, obstruction
- Small bowel cancer
- Colorectal cancer
- Osteoporosis
Ulcerative Colitis
- Pathophyiology
- Presentation
- Investigation
- Management
Pathophysiology
- Diffuse continuous mucosal inflammation (mucosa only), spreads proximally
- Non-granulomatous inflammation, crypt abscesses, goblet cell hypoplasia
Presentation
- Proctitis (confined to rectum) w/ PR bleeding + mucus discharge, increased frequency/urgency of defaecation + tenesmus
- If more extensive - bloody diarrhoea, malaise, anorexia, low grade pyrexia
- Severe abdo pain - ?fulminant colitis, toxic megacolon (CXR to confirm- transverse colon >6cm diameter) or perforation (CT)
- Extra-intestinal: arthritis, erythema nodosum, episcleritis, ant. uveitis, primary sclerosing cholangitis
Mild
- <4movements/day, minimal blood, no pyrexia, HR <90, no anaemia
Mod
- 4-6 movements, mild-sev blood, no pyrexia, tachy or anaemia
Severe
- >6 movements, visible blood, pyrexia, pulse >90 or anaemia
Investigations
- Colonoscopy + biopsies (although avoid in severe colitis as can -> perforation)
- Barium enema: loss of haustrations, superficial ulceration, drainpipe colon
- Faecal calprotectin
Management
- Inducing remission
Proctitis
- rectal aminosalicylate (mesalazine).
- no remission in 4/52: add PO aminosalicylate
- still no rem: add topical or PO steroids
Proctosigmoiditis/left-sided UC:
- rectal aminosalicylate
- no rem in 4/52: add high-dose PO aminosalicylate +/- topical steroid
- if not: stop topicals + give both PO
Extensive disease
- topical AND high-dose PO aminosalicylate
- no rem in 4/52: stop topical + give both high-dose PO
- Extensive disease - topical aminosalicylate AND high-dose PO aminosalicylate
- (if no remission in 4/52
- Severe colitis - hospital admission - IV steroids +/- ciclosporin +/- surgery
Maintaining remission
Following mild/mod flare
- proctitis/proctosigmoiditis: rectal and/or PO aminosalicylate OD or intermittent
- left sided/extensive: low dose PO aminosalicylate
Following severe or 2 or more exac in a year
PO azathioprine + PO mercaptopurine
Complications
- Increased risk of colorectal Ca if UC for >10yrs - colonoscopy w/ biopsies every 1-5yrs
Side Effects of Aminosalicylate drugs e.g. mesalazine, sulfasalazine
(used in Tx of UC and Crohn’s)
- Haematological: Agranulocytosis (need to do FBC in unwell patients)
- Sulphasalazine: rash, oligospermia, megaloblastic anaemia, lung fibrosis
- Mesalazine: pancreatitis, Gi upset, headache, interstitial nephritis
Clostridium Difficile
- Pathophysiology
- Presentation
- Investigations
- Management
Pathophysiology
- Clindamycin and Cephalosporins high risk (cephalexin, cefuroxime, ceftriaxone) also PPIs
Presentation
- Diarrhoea, abdo pain
- raised WCC
- If severe –> toxic megacolon
mild - normal
Mod - elevated WCC (But <15), 3-5 stools/day
Sev - elevated WCC (>15) OR acutely raised Cr OR temp >38.5 OR abdo or radiological signs
Life-threatening: Hypotension, partial/complete ileus, toxic megaolon or CT evidence of severe disease
Investigations
- C. Diff toxin in stool
Management
1st episode
1st line: PO vancomycin 10d
2nd: PO fidoxamicin
3rd: PO vanc +/- IV metro
Recurrent episode
within 12/52 of sx resolution: PO fidoxamicin
after 12/52: PO vanc or fidoxamicin
2 or more prev episodes ?faecal microbiotca transplant
Life-threatening
PO vanc AND IV metronidazole
+ specialist advice, ?surgery
Irritable Bowel Syndrome
- Presentation
- Investigation
- Management
Presentation
- Abdominal pain, Bloating, Change in bowel habit
- Diagnosis if abdo pain w/ relief w defaecation or altered bowel freuency plus 2 of:
- Altered stool passage (strain, urge, incomplete evacuation)
- Abdo bloating (more in women)
- Sx worse w/ eating
- passage of mucus
Red Flags: PR bleed, unexplained weight loss, fam hx bowel/ovarian ca, onset >60yo
Investigations
FBC, ESR/CRP, coeliac screen (tissue transglutaminase antibodies)
Managament
- 1st line depends on main feature
- Pain: antispasmodic e.g. buscopan, mebeverine
- constipation: laxatives
- Diarrhoea: loperamide
- Can try TCAs and SSRI if above ineffective
- General dietary advice: eat: oats, linseed. Avoid: food hard to digest e.g. broccoli + cabbage, sorbitol
- Can try peppermint oil
Coeliac Disease
- Pathophysiology
- Presentation
- Investigation
- Management
- Complications
Pathophysiology
- autoimmune sensitivity to gluten -> villous atrophy -> malabsorption
- People w/ following should be screened:
- Symptoms (below)
- Autoimmune thyroid disease
- Dermatitis herpetiformis
- IBS
- T1DM
- 1st degree relatives w/ coeliac
Presentation
- chronic/intermittent diarrhoea
- failure to thrive (children)
- unexplained n+v
- Prolonged fatigue
- Recurrent abdo pain, cramping, distension
- Sudden/unexpected weight loss
- unexplained IDA/other anaemia
Complications/Extra-intestinal manifestations
- Anaemia: iron, B12, folate (folate def more common than B12)
- Hyposplenism
- Osteoporosis, osteopenia, osteomalacia
- Lactose intolerance
- T-cell lymphoma of small intestine, rarely oesophageal + other malignancy
- Subfertility
- Arthritis + arthralgia
- Neuro: intractable epilepsy, cerebellar ataxia
- Chronic hepatitis
Investigation
- serology:
TTG antibodies + IgA antibodies
Endomyseal antibodies (look IgA def which would give false -ve coeliac result)
(other: anti-gliadin, anti-casein)
- Endoscopic intestinal biopsy (done in all w/ suspected coeliac)
- duodenal +/- jejunal biopsies (vilous atrophy, crypt hyperplasia, lymphocytes)
Management
- Gluten free diet-
Dyspepsia (epigastric discomfort)
- Differentials
- Investigation
- Management
Differentials for Dyspepsia
- Oesophageal: GORD, Ca, acahalsia
- Gastric: peptic ulcer, gastritis, H.pylori, gastric Ca
- Duodenal: ulcer, Ca
- Pancreas: acute/chronic pancreatitis, Ca
- HPB: cholangitis, stones, Ca
Investigation -
- Urgent (2ww) endoscopy:
Dysphagia
Upper abdo mass
>55 w/ weight loss AND either: upper abdo pain, reflux, dyspepsia
- Non-urgent endoscopy
>55 w/:
Treatment resistant dyspepsia
Upper abdo pain + low Hb
Raised platelets or n+v w/ any one of: weight loss, reflux, dyspepsia, upper abdo pain - If not meeting referral criteria = undiagnosed dyspepsia
- Reivew meds
- Lifestyle Advice
- Trial full dose PPI for 1/12 OR ‘test and treat’ H.pylori
(if sx persist try the alternative approach)
- Trial full dose PPI for 1/12 OR ‘test and treat’ H.pylori
N.B. stop PPI 2/52 prior to endoscopy
How is H.Pylori Tested for?
How is it treated?
What are possible complications of H.pylori infection?
Investigations
- Urea breath test: not within 4/52 of treatment w/ abx or PPI. Although eradication not routinely checked for if you were to test would use this.
- Rapid urease test
- Serum antibodies (remains +ve post eradication)
- Gastric biopsy culture
- Stool antigen test
Management
- 7 days of triple therapy:
- PPI + amoxicillin + clarithromycin or metronidazole
- (if pen allergin ppi + clari + metro)
Complications
- peptic ulcer disease (95% of duodenal + 75% of gastric ulcers)
- Gastric cancer
- B-cell lymphoma of MALT (H.pylori eradication -> regression of lymphoma in 80%)
- Atrophic gastritis
N.B. unclear relationship w/ GORD + no role for eradication in GORD management
GORD
- Pathophysiology
- Presentation
- Investigations
- Management
- Complications
Pathophysiology
- Due to reflux of stomach acid into lower oesophagus
- RFs: smoking, alcohol, obesity, age
Presentation
- burning retrosternal/chest pain
- Worse after meals, lying down/bending over
- belching, odynophagia, chronic cough
- Red Flags: dysphagia, weight loss, early satiety, malaise, loss of appetite
Investigation
- Manage as per dyspepsia guidelines until endoscopy done
- GI endoscopy if: >55, Sx >4/52 or resistant to Tx, dysphagia, relapsing sx, weight loss
Management
- Endoscopically proven oesophagitis:
Full dose PPI 1-2/12
if response -> low dose tx as needed; if no response -> double dose for 1/12
- Endoscopically -ve reflux disease:
- Full dose PPI for 1/12
- if response -> PRN low dose
- If no response -> H2RA or prokinetic for 1/12
PPI Side effects: hyponatraemia + hypomagnesaemia, osteoporosis, microscopic colitis, increased risk of C.diff
Complications
- Oesophagitis, ulcers, anaemia, benign strictures
- Barrett’s oesophagus (metalplasia) -> high dose PPI; endoscopical surveillance w/ biopsies every 3-5yr, if dysplasia - endoscopic intervention (ablation or mucosal resection)
- Oesophgeal adenocarcinoma
Pernicious Anaemia
Pathophysiology
Presentation
Investigation
Management
Pathophysiology
- Autoimmune disorder -> vit B12 def.
- Antibodies to intrinsic factor +/- gastric parietal cells
- Vit B12 normally produces red cells + myelinates nerves –> megaloblastic anaemia + neuropathy
RFs: female, other autoimmune conditions, blood group A
Presentation
- Anaemia: lethargy, pallor, SOB
- Neuro:
>Peripheral neuropathy
>Subacute combined degeneration of spinal cord –> progressive weakness, ataxia, paraesthesia –> spasticity + paraplegia
>Neuropsych: memory loss, poor concentration, confusion, depression
>Increased risk gastric Ca
Investigations
- FBC - macrocytic anaemia
- low B12 + folate
- Ab to intrinsic factor (only seen in 50%)
Management
- B12 replacement IM
no neuro features: 3 per week for 2/52, then 3 monthly
(if neuro features need more frequent)
+/- folic acid replacement
Oesophageal Cancer
Pathophysiology
Presentation
Investigation
Management
Pathophysiology
- SCC - upper 2/3rd oesophagus + seen more in less developed countries
- RF: smoking, alcohol, achalasia
- Adenocarcinoma - lower 1/3rd - more in developed countries
- RF: GORD, Barrett’, smoking, achalsia, obesity
Presentation
- Dysphagia - solid then liquid (rapid progression)
- Anorexia + weight loss
- Vomiting
- Odynophagia, hoarseness, melaena, cough
Investigation
- Upper GI endoscopy + biopsy
- CT staging
Management
- Operable disease: surgical resection + chemo
- risk of anastamotic leak + mediastinitis
Achalasia
- Pathophysiology
- Presentation
- Investigation
- Management
Pathophysiology
- failure of oesophageal peristalsis + failure of relaxation of lower oesophageal sphincter
Presentation
- Dysphagia to BOTH solids + liquids
- Heartburn
- Regurgitation of food (can -> cough, aspiration, pneumonia)
- malignant change in small no.
Investigation
- Oesophageal manometry - excessive LOS tone
- barium swallow - expanded oesophagus, fluid level, ‘birds beak’ appearance
- CXR - wide mediastinum, fluid level
Management
- 1st line: Pneumatic dilation
- 2nd: surgery - Heller cardiomyotomy
Haemachromatosis
- Pathophysiology
- Presentation
- Investigations
- Management
Pathophysiology
- Autosomal recessive disorder –> iron accumulation
- HFE gene mutation inheritance.
Presentation
- Often asymptomatic in early disease then initial non-specific symptoms
- Fatigue, erectile dysfunction, arthralgia, DM
- ‘bronze’ skin pigmentation
- Liver: chronic liver disease, hepatomeg, cirrhosis, hepatocellular deposition
- HF (dilated cardiomyopathy)
- Hypogonadism
Liver cirrhosis, DM, hypogonadism, arthropathy = non-reversible
Investigations
- Transferrin saturation = most useful
- genetic testing for HFE mutation
Typically:
- Transferrin sat >55% men, >50% women
- Raised ferritin >500 + iron
- low TIBC
Management
- 1st: venesection
- keep transferrin sat below 50% + ferritin conc below 50
- 2nd: desferrioxamine
Wilson’s Disease
- Pathophysiology
- Presentation
- Investigation
- Management
Pathophysiology
- Autosomal recessive disorder w/ excessive copper deposition in tissues
Presentation
- Age 10-25yo. Children - present w. liver disease. adults w/ neurological disease.
- Liver: hepatitis, cirrhosis
- Neuro: - basal ganglia degeneration in brain, speech, behavioural, psych probs. Asterixis, dementia, parkinsonism.
- Kayser-Fleisher rings
- Renal tubular acidosis
- Haemolysis
Investigations
- Serum reduced caeruloplasmin and reduced total copper
- High 24h urinary copper excretion
- confirmed w/ genetic analysis
Management
- Penicillamine (chelates copper)
Describe the causes and consequences of the following vitamin deficiencies:
- Vitamin B6 (pyridoxine)
- Vitamin B1 (thiamine)
- Vitamin A
Vitamin B6 (pyridoxine)
- Causes: Isoniazid therapy
- Consequences: peripheral neuropathy, sideroblastic anaemia
**Vitamin B1 (thiamine) **
- Causes: Alcohol excess and malnutrition
- Consequences - it is needed by highly aerobic tissues to signs seen in brain (wernicke-korsakoff) + heart (wet beriberi):
-
Wernicke’s Encephalopathy
Signs:
– ataxia **
– oculomotor dysfunction ( nystagmus + ophthalmoplegia (lateral rectus palsy))
– encephlopathy (confusion,** disorientation)
– peripheral sensory neuropathy)
Ix - decreased red cell transkelotase
- MRI
*Korsakoff syndrome *
- Above plus antero- and retrograde amnesia w/ confabulation
Treatment of wernicke’s/korsakoff w/ B1 - pabrinex
N.B. Glucose infusion can trigger wernicke’s in chronic thiamine deficiency
Dry beriberi: peripheral neuropathy
Wet beriberi: dilated cardiomyopathy
