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Gastroenterology Flashcards

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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
PUD management and complications
Lifestyle Medication review H.Pylori eradication PPI Complications - Perforation - Peritonitis - Bleeding Posterior duodenal - Gastroduodenal artery Gastric - Left gastric artery
26
Upper GI bleed DDx
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
27
Upper GI bleed investigations
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!
28
Upper GI bleed management
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
29
Gastric cancer aetiology
Adenocarcinoma Antrum Signet ring cell H.Pylori Alcohol Smoking Diet - Spicy food
30
Gastric cancer presentation / investigations / management
``` Virchow's node - Left clavicular lymph node Dyspepsia Dysphagia GI bleed Weight loss ``` Investigations - OGD + Biopsy - FBC - CT Management - Surgery ± Chemo/Radio
31
Dysphagia DDx
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
32
Intestinal obstruction aetiology
Small bowel - Adhesions - Crohn's - Intussusception - Hernia - Malignancy - Paralytic ileus Large bowel - Cancer - Volvulus - Crohn's - Diverticular disease
33
Intestinal obstruction presentation
``` Absence of stool or flatus Distension Vomiting - Earlier in SBO Tinkling bowel sounds - SBO Abdominal pain ```
34
Intestinal obstruction investigations
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
Intestinal obstruction management
SBO - Drip and suck - IV fluids - NG decompression LBO - Surgery
36
Paralytic ileus aetiology
Cessation of peristalsis - Post-surgical - Drugs - TCA and morphine - Infection - Appendicitis / pancreatitis Electrolyte imbalance - HYPOkalaemia - HYPOnatraemia - HYPERcalcaemia
37
Paralytic ileus presentation / management / complications
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
Volvulus aetiology
Torsion of the bowel on its mesenteric axis Sigmoid - Elderly - Constipation Caecal - Crohn's - Pregnancy - Adhesions
39
Volvulus investigations and management
AXR - Sigmoid - Coffee bean sign - Caecum - Fetal appearance Management - Sigmoid - Flatus tube insertion and rigid sigmoidoscopy - Caecal - Surgery
40
Coeliac aetiology
Gluten intolerance - AI ``` DM1 Vitiligo Pernicious anaemia Addison's Thyroid disorders Down's ```
41
Coeliac presentation
GI - Abdo distension - Pale floating stools - Steatorrhoea - Malabsorption - Fatigue Non-GI - Osteoporosis - Dermatitis herpetiformis - Children - Buttock wasting - Dental problems - Subfertility
42
Coeliac investigations
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
Coeliac management and complications
Flu vaccine - Hyposplenism Complications - T-cell lymphoma - Small bowel carcinoma - Osteoporosis - Subfertility - Hyposplenism - Chronic folate deficiency - Dental problems - Malabsorption - B12
44
Crohn's presentation
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
Crohn's investigations
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
Crohn's management and complications
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
UC presentation
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
UC investigations
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
UC management and complications
5-ASA - Mesalazine - Topical/oral IV steroids - Hydrocortisone ± Ciclosporin Complications - Toxic megacolon
50
Toxic megacolon
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
Diverticular disease
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
Diverticulitis
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
Appendicitis
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
Malabsorption DDx
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
Constipation aetiology
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
Constipation investigations / management / complications
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
IBS aetiology and presentation
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
IBS investigations and management
``` 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
Peritonitis
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
Lower GI tract ischaemia aetiology
SMA / IMA Branch of descending aorta ``` Blood disorders Age - Atherosclerosis AF AAA repair Sickle cell ```
61
Lower GI tract ischaemia presentation
``` 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
Lower GI tract ischaemia investigations and management
ABG - Metabolic acidosis AXR - Thumbprinting CT Management - LMWH - Surgery
63
Bowel cancer aetiology
Most common - Rectum - Sigmoid ``` Poor diet Family Hx PJS - Peutz-Jeghers syndrome FAP - Familial adenomatous polyposis Crohn's Smoking HNPCC ```
64
Bowel cancer presentation and investigations
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
Bowel cancer staging and management
DUKE'S 1. Lamina propria 2. Muscle 3. Lymph nodes 4. Distant mets Management - Hemicolectomy ± Radio/Chemo
66
PR bleed differentials
``` Haemorrhoids Colonic cancer Gastroenteritis Intussusception Ischaemia Diverticular disease Anal fissure Crohn's ```
67
Haemorrhoids pathophysiology
Large vascular cushions in the anal canal External - Below dentate line - Prone to prolapse Internal - Above dentate line - Less prone to prolapse
68
Haemorrhoids risk factors
Low fibre diet Chronic constipation Straining Chronic cough Pregnancy Obesity
69
Haemorrhoids presentation / investigations / management / complications
PR bleed - Fresh blood Painless Anal itch Investigations - DRE + Proctoscopy Management - Manage RFs - Anaesthetic - Rubber band ligation Complications - Anaemia
70
Pseudo-obstruction pathophysiology
Oglive syndrome Dilatation of colon due to adynamic bowel Absence of mechanical obstruction Caecum and ascending colon - Most common
71
Pseudo-obstruction aetiology
Electrolyte imbalance - HYPERcalcaemia - HYPOthyroid - HYPOmagnesaemia Drugs - Opioids - CCBs - Anti-depressants Recent surgery, illness, trauma - MI? Neurological disease - Parkinson's - MS - Hirschsprung's
72
Pseudo-obstruction clinical features
``` Abdo pain and distension Constipation ± Overflow diarrhoea Vomiting - Late feature Distended tympanic abdomen SNT - Tenderness indicates ischaemia ```
73
Pseudo-obstruction DDx and investigations
DDx - Mechanical obstruction - Paralytic ileus - Toxic megacolon Investigations - Investigate cause - AXR - Bowel distension - CT-CAP with IV contrast
74
Pseudo-obstruction management and complications
Conservative - NBM + Drip/Suck Endoscopic decompression Surgery - Resection ± Anastomosis Complications - Toxic megacolon - Bowel ischaemia - Perforation
75
Perianal abscess pathophysiology
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
Perianal abscess clinical features / investigations / management
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
Anal fissure aetiology
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
Anal fissure clinical features
Intermittent! Pain on defecation - "Like passing glass" Tearing sensation on defecation Fresh blood in stool or on paper Anal spasm
79
Anal fissure management
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
Perianal fistula aetiology
Abnormal connection between anal canal and perianal skin IBD Systemic disease - TB, DM, HIV History of anal trauma Previous radiotherapy
81
Perianal fistula clinical features / investigations / management + Classification
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
Pilonidal disease
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
Gastroenteritis aetiology and clinical features
E.Coli Contaminated food products Foreign travel Poor hygiene Extremes of age Clinical features - Diarrhoea - Abdo pain / discomfort - Volume depletion - Fever + N/V
84
Gastroenteritis investigations and management
``` Stool cultures within 3 days of admission WCC ^ Urea ^ Creatinine ^ HYPOkalaemia ``` Management - Supportive - Fluids - Bismuth subsalicylate - Ciprofloxacin - Loperamide

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