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3B > Gastroenterology > Flashcards

Gastroenterology Flashcards

1
Q

Dyspepsia clinical features

A

ROME criteria

Epigastric pain
Post-prandial fullness
Early satiety
Absence of structural disease

Interfering with ADLs

  • At least 3 days a week
  • Over 3 months
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2
Q

Dyspepsia aetiology

A

GORD
Peptic ulcer disease - H.Pylori test!!!
Gastro-oesophageal carcinoma
Achalasia

Medication

  • NSAIDs
  • Steroids
  • SSRIs
  • Bisphosphonates
  • Nitrates
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3
Q

Dyspepsia management

A

PPI trial - Omeprazole

ALARMS - 2ww referral - OGD + FBC

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4
Q

Upper GI red flags

A

ALARMS

Anaemia
Loss of weight
Anorexia
Recent onset > 55
Melaena
Swallowing difficulty
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5
Q

GORD aetiology

A

LOS fails to close
Gastric contents leak into oesophagus

Smoking
Obesity
Pregnancy
Fatty/heavy meals
Alcohol
Hiatus hernia
CREST
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6
Q

GORD presentation

A

CHARM B

Cough / Wheeze 
Hoarse voice
Aspiration pneumonia
Retrosternal / epigastric pain 
Metallic taste
Belching
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7
Q

GORD investigations

A

ALARMS - 2ww referral - OGD + FBC

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8
Q

GORD management

A

Lifestyle changes

Alginate therapy - Gaviscon

Full dose PPI - 1-2 months

Response - Switch to lower dose

No response…

  • Endoscopic +ve - Double PPI
  • Endoscopic -ve - H2RA - Famotidine
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9
Q

GORD complications

A 
Aspiration pneumonia
Barrett's - Oesophageal adenocarcinoma
Hoarse voice
Strictures / ulcers
Anaemia
Oesophagitis
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10
Q

Achalasia pathophysiology

A

Loss of ganglionic cells in Auerbach’s plexus - LOS

Food fails to pass to stomach

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11
Q

Achalasia presentation and investigations

A

Solids and liquids fail to pass into stomach

Dysphagia
Regurgitaiton

Investigations

  • Oesophageal manometry
  • Barium swallow - Beak sign
  • OGD - Rule out malignancy
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12
Q

Achalasia management and complications

A

Botox injections
Heller cardiomyotomy
Balloon stent

Nitrates / CCB - Resistant disease unfit for surgery

Complications

  • Oesophageal SCC
  • Perforation in surgery
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13
Q

Oesophageal cancer aetiology

A

Top 2/3 - Adenocarcinoma - Barrett’s (GORD)

Lower 1/3 - SCC - Achalasia

Risk factors

  • Family history
  • Smoking
  • Alcohol
  • Nitrosamines - Bacon, beer, cheese, milk, fish
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14
Q

Oesophageal cancer presentation

A

Progressive dysphagia
(Solids to liquids)

Cough
Hoarse voice
Dyspepsia

+ ALARMS

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15
Q

Oesophageal cancer investigations / management / complications / prognosis

A

OGD + Biopsy
CT

Management - Surgery ± Chemo/Radio

Complications - Anastomotic leak - Mediastinitis

Prognosis - Poor

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16
Q

Hiatus hernia

A

Presentation

  • Dyspepsia
  • Dysphagia

Investigations

  • Barium swallow
  • CXR
  • OGD

Management - PPI / surgery

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17
Q

Inguinal hernias

A

Direct

  • Posterior wall of inguinal canal
  • Through Hesselbach’s triangle

Indirect

  • Through deep inguinal ring
  • Patent processus vaginalis

Risk factors - Increased intra-abdominal pressure

Presentation - Lump in groin - Reducible

Complications - Strangulation / obstruction

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18
Q

Stomach histology

A

D-cells - Somatostatin - Decreases stomach acid release

Parietal cells

  • Intrinsic factor - B12 absorption TI
  • HCl - Denatures protein, converts pepsinogen to pepsin

G-cells - Gastrin - Stimulates HCl release from parietal cells

Chief cells - Pepsinogen - Converted to pepsin by HCl - Protease

Foveolar cells - Mucus and bicarbonate

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19
Q

H.Pylori aetiology

A

Gram -ve curved bacillus
Secretes urease

Associated with…

  • Peptic ulcer disease
  • Gastric cancer
  • MALT lymphoma
  • Iron deficiency - Microcytic
  • Atrophic gastritis
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20
Q

H.Pylori investigations

A

C-13 urea breath test - CI if…

  • PPI for 2 weeks
  • Abx for 4 weeks

Stool antigen test
Serum antibodies
Gastroscopy + Biopsy
Campylobacter-like organism (CLO) test

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21
Q

H.Pylori management

A

Triple therapy - 7-14 days

PPI + Clari + Amox

Penicillin allergy…
PPI + Clari + Met

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22
Q

PUD risk factors

A

H.Pylori
Alcohol

Drugs

  • NSAIDs
  • SSRIs
  • Steroids
  • Bisphosphonates
  • Nitrates
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23
Q

PUD presentation

A

Epigastric pain

Gastric - Worse after eating
Duodenal - Relieved by eating
- Small bowel secretions are alkali
+ Back pain

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24
Q

PUD investigations

A

H.Pylori screen

Alarms - 2ww referral - OGD + FBC

No risk factors - OGD + Biopsy

  • Zollinger-Ellison syndrome
  • Gastrin secreting tumour
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25
Q

PUD management and complications

A

Lifestyle
Medication review

H.Pylori eradication
PPI

Complications

  • Perforation - Peritonitis
  • Bleeding

Posterior duodenal - Gastroduodenal artery
Gastric - Left gastric artery

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26
Q

Upper GI bleed DDx

A

Mallory-Weiss tear

  • Alcohol
  • Hyperemesis gravidarum

Varices - Liver disease

PUD

  • Perforated artery
  • Malaena

Oesophagitis - Streaky blood

Oesophageal cancer

  • Weight loss
  • Progressive dysphagia

Oesophageal rupture - Boerhaave syndrome

  1. Vomiting
  2. Chest pain
  3. Subcutaneous emphysema
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27
Q

Upper GI bleed investigations

A

FBC
U&E - Isolated Urea ^^^
Coagulation screen

Blatchford score - Assess need for intervention
Rockall score - Morbidity and mortality in upper GI bleeds

OGD - Find cause!

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28
Q

Upper GI bleed management

A

ABCDE

Massive haemorrhage protocol

2 large bore cannulas
Cross-match 2 units of blood
4:4:1 - RBC : FFP : Platelets
Tranexamic acid

Varices - Terlipressin + Abx

OGD - Sclerotherapy/banding
Balloon - Sengstaken Blakemore tube - Minnesota tube

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29
Q

Gastric cancer aetiology

A

Adenocarcinoma
Antrum
Signet ring cell

H.Pylori
Alcohol
Smoking
Diet - Spicy food

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30
Q

Gastric cancer presentation / investigations / management

A 
Virchow's node - Left clavicular lymph node
Dyspepsia
Dysphagia
GI bleed
Weight loss

Investigations

  • OGD + Biopsy
  • FBC
  • CT

Management - Surgery ± Chemo/Radio

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31
Q

Dysphagia DDx

A

Oesophageal cancer - Progressive - Solids to liquids
Candidiasis - History of DM or steroid use (inhalers)
Strictures - GORD
Hernia - Regurgitation
Neurological - Stroke, MS, MG
Systemic sclerosis - Hallitosis and regurgitation
Achalasia - Solids AND liquids
Oesophagitis - History of GORD
GORD - Dyspepsia

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32
Q

Intestinal obstruction aetiology

A

Small bowel

  • Adhesions
  • Crohn’s
  • Intussusception
  • Hernia
  • Malignancy
  • Paralytic ileus

Large bowel

  • Cancer
  • Volvulus
  • Crohn’s
  • Diverticular disease
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33
Q

Intestinal obstruction presentation

A 
Absence of stool or flatus
Distension
Vomiting - Earlier in SBO
Tinkling bowel sounds - SBO
Abdominal pain
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34
Q

Intestinal obstruction investigations

A

Bloods - Electrolytes

AXR (+ CXR for pneumoperitoneum)

  • Pneumoperitoneum if perforated - Rigler’s sign
  • Distended loops of proximal bowel
  • Loss of haustra
  • Valvula conniventes - SBO
  • Fluids level
35
Q

Intestinal obstruction management

A

SBO - Drip and suck

  • IV fluids
  • NG decompression

LBO - Surgery

36
Q

Paralytic ileus aetiology

A

Cessation of peristalsis

  • Post-surgical
  • Drugs - TCA and morphine
  • Infection - Appendicitis / pancreatitis

Electrolyte imbalance

  • HYPOkalaemia
  • HYPOnatraemia
  • HYPERcalcaemia
37
Q

Paralytic ileus presentation / management / complications

A

Bowel obstruction
Absent bowel sounds - No bowel movement

Management - Treat cause

  • Correct electrolyte imbalance
  • NG decompression
  • Surgery
  • Metoclopramide - Increase bowel movement

Complications

  • Necrosis
  • Peritonitis
38
Q

Volvulus aetiology

A

Torsion of the bowel on its mesenteric axis

Sigmoid

  • Elderly
  • Constipation

Caecal

  • Crohn’s
  • Pregnancy
  • Adhesions
39
Q

Volvulus investigations and management

A

AXR

  • Sigmoid - Coffee bean sign
  • Caecum - Fetal appearance

Management

  • Sigmoid - Flatus tube insertion and rigid sigmoidoscopy
  • Caecal - Surgery
40
Q

Coeliac aetiology

A

Gluten intolerance - AI

DM1
Vitiligo
Pernicious anaemia
Addison's
Thyroid disorders
Down's
41
Q

Coeliac presentation

A

GI

  • Abdo distension
  • Pale floating stools
  • Steatorrhoea
  • Malabsorption - Fatigue

Non-GI

  • Osteoporosis
  • Dermatitis herpetiformis
  • Children - Buttock wasting
  • Dental problems
  • Subfertility
42
Q

Coeliac investigations

A
  1. Anti-TTG
    + Anti-endomysial antibodies
    + Anti-gliadin

Malabsorption screen - B12, etc.

Biopsy - Jejunum - 6 weeks

  • Crypt hyperplasia
  • Villous atrophy
  • Increased intra-epithelial lymphocytes
43
Q

Coeliac management and complications

A

Flu vaccine - Hyposplenism

Complications

  • T-cell lymphoma
  • Small bowel carcinoma
  • Osteoporosis
  • Subfertility
  • Hyposplenism - Chronic folate deficiency
  • Dental problems
  • Malabsorption - B12
44
Q

Crohn’s presentation

A

Associated with PSC!

GI

  • Mouth ulcers
  • Abdominal pain - RIF - Dance sign
  • Perianal disease
  • Change in bowel habit - Tenesmus + Mucus
  • Weight loss

Non-GI

  • Skin - Pyoderma gangrenosum / erythema nodosum
  • Eyes - Anterior uveitis
  • Arthritis - Enteropathic
  • Malabsorption - Fatigue
45
Q

Crohn’s investigations

A

BBB

Bloods

  • FBC - Anaemia
  • Iron studies
  • B12 / Folate
  • ESR / CRP
  • Calcium profile

Stool sample

  • Faecal calprotectin
  • Faecal Immunochemical Testing - Rule out carcinoma

Biopsy

  • Skip lesions
  • Transmural inflammation
  • Goblet cells
  • NC granuloma

Barium enema

  • Rose thorn ulcers
  • String sign
  • Fistulas
46
Q

Crohn’s management and complications

A

Stop smoking!

Acute - Topical/PO prednisolone

Long-term

  • Azathioprine - Measure TPMT before prescribing!
  • Mercaptopurine
  • Methotrexate

Surgery - Ileocaecal resection

Complications

  • Increased bowel cancer risk
  • Obstruction
  • Malabsorption
  • Osteoporosis
47
Q

UC presentation

A

IC valve to rectum - No anal involvement

Associated with PSC

GI

  • Bloody diarrhoea
  • Change in bowel habit - Tenesmus + Urgency
  • No anal disease
  • LIF pain

Non-GI

  • Eyes - Anterior uveitis
  • Skin - Pyoderma gangrenosum / erythema nodosum
  • MSK - Enteropathic arthritis
48
Q

UC investigations

A

Bloods

  • FBC - Anaemia
  • Iron studies
  • B12 and folate
  • ESR / CRP

Stool sample

  • Faecal calprotectin
  • Faecal Immunochemical Testing - Rule out carcinoma

Barium enema - Lead pipe!

Biopsy

  • Continuous inflammation up to the submucosa
  • Crypt abscesses
  • Goblet cell depletion
  • Pseudopolyps
49
Q

UC management and complications

A

5-ASA - Mesalazine - Topical/oral

IV steroids - Hydrocortisone ± Ciclosporin

Complications - Toxic megacolon

50
Q

Toxic megacolon

A

Aetiology - UC / Crohn’s

  • Clari
  • Cipro
  • Co-amox
  • Cef
  • PPIs

Investigations

  • Large transverse colon on AXR
  • C.Diff toxin test
  • WCC ^^^

Management - Met / Vanc

51
Q

Diverticular disease

A

Mucosa herniates through muscular bowel wall

Aetiology

  • Poor diet - Lack of fibre
  • Drugs - Opioids, etc.

Presentation - Asymptomatic?

  • Blood in stool
  • Change in bowel habit
  • Diverticulitis

Investigations

  • FIT
  • Colonoscopy
  • Barium enema
  • FBC

Management - Treat cause
- Stimulant laxative - Senna

Complications

  • Obstruction
  • Diverticulitis
  • Anaemia
52
Q

Diverticulitis

A

Infection of diverticular disease

Presentation

  • Fever
  • LIF pain / guarding
  • Blood in stool
  • Change in bowel habit
  • N/V
  • Urinary symptoms secondary to irritation

Investigations

  • WCC
  • CRP
  • CXR - Pneumoperitoneum
  • AXR - Obstruction

Management

  • Co-amox
  • IV if no improvement after 72 hours
53
Q

Appendicitis

A

Presentation

  • Fever + N/V
  • Peri-umbilical pain - Radiating to McBurney’s point
  • Guarding
  • Spasming
  • Rebound tenderness
  • Rovsing’s sign - Pain in RIF when palpating LIF

Investigations

  • WCC
  • CRP
  • Pregnancy test - Ectopic?
  • Urine dip
  • Septic screen

Management - Lap appy
Complications - Peritonitis / shock

54
Q

Malabsorption DDx

A

Intestinal

  • Coeliac
  • Lactose intolerance
  • IBD
  • Short bowel syndrome
  • Chronic diarrhoea - HIV
  • Tropical sprue

Pancreas

  • Chronic pancreatitis
  • Cystic fibrosis
  • Pancreatic cancer

Biliary tree

  • Obstruction
  • PBC

Malignancy - Lymphoma

55
Q

Constipation aetiology

A

Stuff going in…

  • Drugs - Opioids / TCA
  • Low fibre diet

Endocrine

  • Hypercalcaemia
  • Hypothyroid

GI

  • Coeliac
  • IBS/IBD
  • Diverticular disease

Gynae causes

  • Ovarian cyst
  • Ovarian cancer
  • Prolapse
56
Q

Constipation investigations / management / complications

A

Investigations

  • Colonoscopy if red flags
  • FIT
  • Faecal calprotectin
  • CRP
  • Ca125

Management - Treat cause

  • Bulk forming - Ispaghula husk - CI with opioids
  • Osmotic - Movicol
  • Stimulant - Senna - Good for opioids
  • Lactulose

Complications - DO PUSH

  • Diverticulosis
  • Overflow diarrhoea
  • Perianal disease
  • Urinary retention
  • Sigmoid volvulus
  • Haemorrhoids
57
Q

IBS aetiology and presentation

A

Precipitated by stress

Presentation - Criteria…
- Abdominal pain relieved by defecation and associated with change in bowel habit
+ 2 of…
- Stool change - Incomplete emptying, straining, urgency
- Bloating
- Mucus
- Worse on eating

58
Q

IBS investigations and management

A 
Anti-TTG - Coeliac
FBC
Ca125
FIT
Faecal calprotectin - IBD
ESR / CRP

Management

  • Meditation / CBT
  • FODMAP diet
  • Pain - Mebeverine - Antispasmodic / Buscopan
  • Diarrhoea - Loperamide -Opioid agonist
  • Constipation - Ispaghula husk
59
Q

Peritonitis

A

Presentation - Severe abdominal pain - Worse on movement

Aetiology

  • Pancreatitis
  • Appendicitis
  • PUD perforation
  • Diverticulitis
  • Bowel obstruction / perforation
  • Ovarian cyst rupture

Investigations

  • AXR - Rigler’s sign
  • CXR - Pneumoperitoneum
  • Lipase / Amylase
  • WCC / CRP
  • Septic screen

Management - Treat cause

60
Q

Lower GI tract ischaemia aetiology

A

SMA / IMA
Branch of descending aorta

Blood disorders
Age - Atherosclerosis
AF
AAA repair
Sickle cell
61
Q

Lower GI tract ischaemia presentation

A 
Abdo pain
PR bleed
Diarrhoea
Fever
Metabolic acidosis

“70 year old woman
PMH - AF/CVD
Presents with central abdo pain, pyrexia, diarrhoea, blood PR
ABG shows metabolic acidosis”

62
Q

Lower GI tract ischaemia investigations and management

A

ABG - Metabolic acidosis
AXR - Thumbprinting
CT

Management

  • LMWH
  • Surgery
63
Q

Bowel cancer aetiology

A

Most common

  • Rectum
  • Sigmoid
Poor diet
Family Hx
PJS - Peutz-Jeghers syndrome
FAP - Familial adenomatous polyposis
Crohn's
Smoking
HNPCC
64
Q

Bowel cancer presentation and investigations

A

Change in bowel habit
PR bleeding
Weight loss
Obstruction

Investigations

  • FIT screening - 60-74 - Every 2 years
  • CEA - Marker
  • PR exam
  • Colonoscopy and biopsy
  • CT
65
Q

Bowel cancer staging and management

A

DUKE’S

  1. Lamina propria
  2. Muscle
  3. Lymph nodes
  4. Distant mets

Management - Hemicolectomy ± Radio/Chemo

66
Q

PR bleed differentials

A 
Haemorrhoids
Colonic cancer
Gastroenteritis
Intussusception
Ischaemia
Diverticular disease
Anal fissure
Crohn's
67
Q

Haemorrhoids pathophysiology

A

Large vascular cushions in the anal canal

External - Below dentate line - Prone to prolapse
Internal - Above dentate line - Less prone to prolapse

68
Q

Haemorrhoids risk factors

A

Low fibre diet
Chronic constipation

Straining
Chronic cough

Pregnancy
Obesity

69
Q

Haemorrhoids presentation / investigations / management / complications

A

PR bleed - Fresh blood
Painless
Anal itch

Investigations - DRE + Proctoscopy

Management

  • Manage RFs
  • Anaesthetic
  • Rubber band ligation

Complications - Anaemia

70
Q

Pseudo-obstruction pathophysiology

A

Oglive syndrome
Dilatation of colon due to adynamic bowel
Absence of mechanical obstruction
Caecum and ascending colon - Most common

71
Q

Pseudo-obstruction aetiology

A

Electrolyte imbalance

  • HYPERcalcaemia
  • HYPOthyroid
  • HYPOmagnesaemia

Drugs

  • Opioids
  • CCBs
  • Anti-depressants

Recent surgery, illness, trauma - MI?

Neurological disease

  • Parkinson’s
  • MS
  • Hirschsprung’s
72
Q

Pseudo-obstruction clinical features

A 
Abdo pain and distension
Constipation ± Overflow diarrhoea
Vomiting - Late feature
Distended tympanic abdomen
SNT - Tenderness indicates ischaemia
73
Q

Pseudo-obstruction DDx and investigations

A

DDx

  • Mechanical obstruction
  • Paralytic ileus
  • Toxic megacolon

Investigations

  • Investigate cause
  • AXR - Bowel distension
  • CT-CAP with IV contrast
74
Q

Pseudo-obstruction management and complications

A

Conservative - NBM + Drip/Suck
Endoscopic decompression
Surgery - Resection ± Anastomosis

Complications

  • Toxic megacolon
  • Bowel ischaemia
  • Perforation
75
Q

Perianal abscess pathophysiology

A

Collection of pus within SC tissue of anus
Tracked from tissue surrounding anal sphincter

E.Coli or Staph.A

Associated with…

  • IBD - Crohn’s
  • DM
  • Malignancy
  • Anorectal conditions
76
Q

Perianal abscess clinical features / investigations / management

A

Pain around anus - Worse on sitting
Hardened tissue
Pus-like discharge
Longstanding - Systemic infection - Fever and tachycardia

Clinical diagnosis ± DRE

Investigate underlying cause

Management - I&D under LA - Heals in 3-4 weeks

77
Q

Anal fissure aetiology

A

Split in the skin of distal anal canal

Risk factors

  • Hard stool
  • Pregnancy - 3rd trimester
  • Opiate analgesia - Constipation
  • IBD
  • STIs - HIV, syphilis, herpes, etc.
78
Q

Anal fissure clinical features

A

Intermittent!

Pain on defecation - “Like passing glass”
Tearing sensation on defecation
Fresh blood in stool or on paper
Anal spasm

79
Q

Anal fissure management

A

Acute - Conservative

  • High fibre diet
  • Adequate fluid intake
  • Bulk forming laxative - Ispaghula husk
  • Lubricants - Prior to defecation
  • Topical anaesthetic
  • Analgesia - Topical GTN / Diltiazem

Chronic - As above, and consider…

  • Surgery - Sphincterotomy
  • Botulinum toxin
80
Q

Perianal fistula aetiology

A

Abnormal connection between anal canal and perianal skin

IBD
Systemic disease - TB, DM, HIV
History of anal trauma
Previous radiotherapy

81
Q

Perianal fistula clinical features / investigations / management

+ Classification

A

Intermittent or continuous discharge onto perineum

  • Blood
  • Mucus
  • Pus
  • Faeces

Examination - DRE

  • Proctoscopy
  • MRI - Complex fistulae

Goodsall rule
Park’s classification system

Management

  • Conservative
  • Surgical - Fistulotomy / Seton placement
82
Q

Pilonidal disease

A

Young men of working age
Ingrowing hair follicle
Chronic inflammation

Clinical features

  • Discharge
  • Pain/swelling
  • Sinus tracts

Asymptomatic - Hair removal and local hygiene

Symptomatic

  • Surgical closure
  • Amox
  • Hair removal
  • Paracetamol
83
Q

Gastroenteritis aetiology and clinical features

A

E.Coli

Contaminated food products
Foreign travel
Poor hygiene
Extremes of age

Clinical features

  • Diarrhoea
  • Abdo pain / discomfort
  • Volume depletion
  • Fever + N/V
84
Q

Gastroenteritis investigations and management

A 
Stool cultures within 3 days of admission
WCC ^ 
Urea ^
Creatinine ^ 
HYPOkalaemia

Management - Supportive - Fluids

  • Bismuth subsalicylate
  • Ciprofloxacin
  • Loperamide

3B (23 decks)

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