Gastroenterology - Presenting problems Flashcards

Question

Summarise the causes of haematemesis?

Answer 1

This can best be remembered as "VINTAGE": Varices Inflammation (e.g. oesophagitis or peptic ulcer) Neoplasia (e.g. oesophageal or gastric) Trauma - 1) Mallory-Weiss tear - 2) Surgery, ERCP, aorto-duodenal fistula - 3) Hypovolaemic shock: ischaemic, stress ulcer in stomach Angiodysplasia + other vascular abnormalities - angiodysplasia (dilated vessel complexes in clusters) - hereditary haemorrhagic telangiectasia (dilated vessels ALL over bowel wall) - others (e.g. Dieulafoy lesion, PAN) Generalised bleeding disorder Epistaxis Exogenous

Answer 2

1) IV access 2) Clinical assessment - risk of complications related to circulatory status, liver disease, and comorbidity (i.e. cardiorespiratory, cerebrovascular or renal disease that increases the hazards of endoscopy and surgery) 3) Bloods - cross match blood, check FBC, LFTs, U+E and Clotting (as a minimum) 4) Resuscitation - oxygen is given to patients in shock. IV crystalloid infusion restores BP, and blood transfusion is indicated if there is shock and active bleeding. Antibiotics are given in chronic liver 5) Endoscopy - ideally all patients admitted with upper gastrointestinal haemorrhage should undergo Upper GI endoscopy within 24 hours of admission. In those who are unstable this should occur immediately after resuscitation or in tandem with it 6) Monitoring - hourly pulse, BP and urine output should be monitored

Answer 3

Patients > 60 years Continued bleeding despite endoscopic intervention Recurrent bleeding Known cardiovascular disease with poor response to hypotension

Answer 4

Patients with suspected varices should receive terlipressin prior to endoscopy. Varices should be banded or subjected to sclerotherapy. If this is not possible owing to active bleeding then a Sengaksten- Blakemore tube (or Minnesota tube) should be inserted. This should be done with care; gastric balloon should be inflated first and oesophageal balloon second. Remember the balloon with need deflating after 12 hours (ideally sooner) to prevent necrosis. Portal pressure should be lowered by combination of medical therapy +/- TIPSS. Identifiable bleeding points should receive combination therapy of injection of adrenaline and either a thermal or mechanical treatment. All who have received intervention should receive a continuous infusion of a proton pump inhibitor (IV omeprazole for 72 hours) to reduce the re-bleeding rate.

Answer 5

The need for admission and timing of endoscopic intervention may be predicted by using the Blatchford score. This considers a patients Hb, serum urea, pulse rate and blood pressure. Those patients with a score of 0 are low risk, all others are considered high risk and require admission and endoscopy.

Answer 6

The requirement for pre endoscopic proton pump inhibition is contentious. In the UK the National Institute of Clinical Excellence guidelines suggest the pre endoscopic PPI therapy is unnecessary. Whilst it is accepted that such treatment has no impact on mortality or morbidity a Cochrane review of this practice in 2007 did suggest that it reduced the stigmata or recent haemorrhage at endoscopy. As a result many will still administer PPI to patients prior to endoscopic intervention.

Answer 7

Following endoscopy it is important to calculate the Rockall score for patients to determine their risk of rebleeding and mortality. A score of 3 or less is associated with a rebleeding rate of 4% and a very low risk of mortality and identifies a group of patients suitable for early discharge.

Answer 8

This typically presents as bright red or dark red blood per rectum. Colonic bleeding rarely presents as malaena type stool, this is because blood in the colon has a powerful laxative effect and is rarely retained long enough for transformation to occur and because the digestive enzymes present in the small bowel are not present in the colon. Up to 15% of patients presenting with haemochezia will have an upper gastrointestinal source of haemorrhage. As a general rule right sided bleeds tend to present with darker coloured blood than left sided bleeds. Haemorrhoidal bleeding typically presents as bright red rectal bleeding that occurs post defecation either onto toilet paper or into the toilet pan. It is very unusual for haemorrhoids alone to cause any degree of haemodynamic compromise.

Answer 9

Remember these by using "DRIPPING TAPS" Diverticulae (e.g. colonic, Meckel's, jejunal) Rectal Infection Polpys - both benign and neoplastic Inflammation (e.g. ulcerative colitis - blood diarrhoea) Neoplasia (e.g. carcinoma, lymphoma) Gastric upper bowel bleeding (bloody if rapid transit) Trauma (e.g. surgery, radiation colitis) Arterial/ Angiodysplasia/ AVM) Pseudomembranous colitis Systemic (e.g. coagulopathy, amyloid)

Answer 10

Colonic diverticular disease: this is the most common cause. Patients present with profuse, red or maroon diarrhoea and shock. Bleeding almost always stops spontaneously, but if not, the diseased segment is located by angiography or colonoscopy and resected. Illeal (e.g. Meckel's diverticulum): presents with childhood bleeding Jejunal: bleeding usually presents with malabsorption + vitamin B12 deficiency due to bacterial overgrowth

Answer 11

1) Bacterial: Salmonella, Campylobacter, E.coli, pseudomembranous colitis, TB 2) Other: HIV, CMV, Candida 3) Parasites: amoebic dysentry, hookworm (melaena)

Answer 12

Prompt correction of any haemodynamic compromise is required. Unlike upper gastrointestinal bleeding the first line management is usually supportive. This is because in the acute setting endoscopy is rarely helpful. When haemorrhoidal bleeding is suspected a proctosigmoidoscopy is reasonable as attempts at full colonoscopy are usually time consuming and often futile. In the unstable patient the usual procedure would be an angiogram (either CT or percutaneous), when these are performed during a period of haemodynamic instability they may show a bleeding point and may be the only way of identifying a patch of angiodysplasia. In others who are more stable the standard procedure would be a colonoscopy in the elective setting. In patients undergoing angiography attempts can be made to address the lesion in question such as coiling. Otherwise surgery will be necessary. In patients with ulcerative colitis who have significant haemorrhage the standard approach would be a sub total colectomy, particularly if medical management has already been tried and is not effective.

Answer 13

If upper endoscopy and colonoscopy are inconclusive, mesenteric angiography usually identifies the site and embolisation can be used to stop the bleeding. If angiography is negative, double balloon enteroscopy or wireless capsule endoscopy can be employed to identify a bleeding source in the small intestine. When all else fails, laparotomy with on-table endoscopy is indicated.

Answer 14

Occult bleeding (no visible blood) may reach 200 mL/day, cause iron deficiency anaemia and signify serious disease. The most important cause is colorectal cancer, which may have no GI symp- toms. GI investigations should be considered in any patient with unexplained iron deficiency anaemia. A negative faecal occult blood (FOB) test does not exclude important GI disease. FOB is now only used in population screening for bowel cancer.

Answer 15

Diarrhoea: > 3 loose or watery stool per day or >250g stool per day Acute diarrhoea < 14 days Chronic diarrhoea > 14 days

Answer 16

1) Invasive 2) Secretory 3) Osmotic

Answer 17

Pathogens invade enterocytes causing low volume diarrhoea, which contains blood and leukocytes (i.e. dysentery). It is caused by Shigella spp, Campylobacter, Salmonella and Entamoeba histolytica

Answer 18

Faecal smear for leukocytes - positive in most cases | Order stool culture, stool for O&P (ova and parasites) and stool antigen

Answer 19

Loss of isotonic fluid causing high volume diarrhoea. Mechanisms include: - laxatives - enterotoxins stimulate Cl- channels regulated by cAMP and cGMP - serotonin increases bowel motility There is no inflammation in the bowel mucosa. Diarrhoea persists with fasting.

Answer 20

1) Laxatives - esp. phenolphthalein containing, e.g. senna, bisacodyl - danger of melanosis coli (black bowel syndrome) 2) Infection (toxin mediated): i) Food poisoning (toxin or organism pre formed within food) - toxin mediated: staph aureus, Clostridium perfringens ii) Gastroenteritis (i.e. organism colonizes and multiplies within bowel) - toxin mediated: cholera, enterotoxigenic E.coli 3) Increased serotonin: carcinoid syndrome

Answer 21

Faecal smear for leukocytes - negative in most cases Increased 5-HIAA: carcinoid syndrome Stool osmotic gap <50mOsm/kg

Answer 22

Osmotically active substance is drawing hypotonic solution out of the bowel, causing high volume diarrhoea but no inflammation in the bowel mucosa.

Answer 23

1) Malabsorption - disaccharidase deficiency - giardiasis - ANY cause of malabsorption 2) haemorrhage into bowel 3) Ingestion of poorly absorbable solutes (e.g. magnesium sulfate laxatives)

Answer 24

Faecal smear for leukocytes - negative | Stool osmotic gap >100mOsm/kg

Answer 25

300 mOsm/kg (value used to represent normal POsm) Osmotic gap <50 mOsm/kg from POsm is a secretory diarrhea. - Indicates that diarrheal fuid POsm approximates normal POsm Osmotic gap >100 mOsm/kg from POsm is an osmotic diarrhea. - Indicates a hypotonic loss of stool due to presence of osmotically active substances

Answer 26

Think of "SOILINGS" Secretory - as well as infection and toxic, there are also systemic causes (e.g. thyrotoxicosis, hypoadrenalism) Osmotic Inflammation or Ischaemia (e.g. UC, vasculitis) Laxatives and other drugs - e.g. erythromycin, prokinetics Irritable bowel syndrome Neuropathy - autonomic, e.g. diabetes Gastrectomy Structural - e.g. rectal adenomas, neoplasia, diverticular disease Special - e.g. alcohol, overflow (faecal impaction)

Answer 27

The most common cause is irritable bowel syndrome, in which diarrhoea is most severe before and after breakfast and rarely occurs at night. At other times the patient is constipated. The stool often contains mucus but never blood, and 24-hr stool volume is <200 g. Chronic diarrhoea can also be due to inflammatory or neoplastic disease of the colon or small bowel, or to malabsorption. Negative investigations suggest irritable bowel syndrome.

Answer 28

Criteria useful for diagnosing IBS. Includes: 1) Abdo-rectal pain: relieved by defacation, radiates to thighs + back, bloating 2) Stool frequency: >3x/day or <3/week 3) Stool form: hard pellets, watery, mucus Exclusion criteria: onset > 40 years, bloody stool, weight loss + normal sigmoidoscopy

Answer 29

Chronic diarrhoea with increased faecal excretion of fats (steatorrhoea). Concurrent deficiencies in fat soluble vitamins, minerals, carbohydrates, and proteins may also occur. Clinically, chronic diarrhoea and weight loss in a patient with a normal diet suggests malabsorption.

Answer 30

Bulky, pale, offensive stools that float (statorrhoea) signify fat malabsorption. Abdominal distension, borborygmi, cramps and undigested food in the stool may be present. Malaise, lethargy, peripheral neuropathy and symptoms related to vitamin or mineral deficiencies may occur.

Answer 31

Malabsorption results from abnormalities of the three components of normal digestion: 1) Intraluminal maldigestion due to deficiency of bile or pancreatic enzymes 2) Mucosal malabsorption from small bowel resection or damage to the small intestinal epithelium 3) ‘Post-mucosal’ lymphatic obstruction preventing the uptake of absorbed lipids into lymphatic vessels

Answer 32

Pancreatic insufficiency is most commonly caused by chronic pancreatitis (most commonly due to alcohol in adults and cystic fibrosis in children). Dietary triglyceride is digested by pancreatic lipase, which is deficient in chronic pancreatitis. Fats are undigested producing fatty stool. Maldigestion of proteins is also present. Due to reduced pancreatic trypsin. Carbohydrate absorption is NOT affected because amylase is present in the salivary glands and disaccharidases are present in the brush border of intestinal epithelium.

Answer 33

1) Inadequate synthesis of bile acids from cholesterol (cirrhosis) 2) Intrahepatic/ extrahepatic blockage of bile - e.g. PBC, stone in common bile duct 3) Bacterial overgrowth in small bowel with destruction of bile salts/ acids - e.g. small bowel diverticula, autonomic neuropathy 4) Excess binding of bile salts 5) Terminal ileal disease - prevents recycling of bile acids, e.g. Crohns disease, or resection

Answer 34

Bile salts/ acids produce micelles to enhance reabsorption of fats by the small intestinal villi. Micelles contain MGs, FAs and fat soluble vitamins. Note that ALL fat soluble vitamins (i.e. A, D, E and K) are packaged into micelles so any disease producing maldigestion of fats also produces deficiencies of all the fat soluble vitamins.

Answer 35

1) Damage to villi (coeliac disease) - villi increase absorptive surface of the small intestine - required to absorb micelles into enterocytes - loss of villi lead to loss of micelles in stools 2) Apoprotein B48 in enterocytes is important in resynthesizing TGs and packaging them into chylomicrons - loss of enterocytes and/or deficiency of apoB48 diminishes formation of chylomicrons 3) ApoB48 also important for transporting chylomicrons into lymphatics - deficiency of apoB48 or lymphatic blockage in the intestinal cells (Whipple's disease) decreases chylomicron transportation in the blood

Answer 36

First enquire about symptoms of steatorrhoea. If present do preliminary bloods for U&Es, immunoglobulins, Ca++, Mg++, FBC, clotting, albumin, folate, B12, coeliac antibodies. Second investigate small intestine: - duodenal biopsy - barium studies - faecal calprotectin If these are NORMAL, investigate the pancreas: - pancreatic function tests - faecal elastase - ultrasound scan - MRCP If these are NORMAL, consider bile salt malabsorption - SeHCAT scan* - serum 7 alpha hydroxycholestenone *nuclear medicine test using a gamma-emitting selenium molecule in selenium homocholic acid taurine or tauroselcholic acid (SeHCAT) scans are done 7 days apart to assess the retention/loss of radiolabelled 75SeHCAT

Answer 37

Unplanned weight loss of >3 kg over 6 months is significant. Pathological weight loss can be caused by psychiatric illness, systemic disease, GI causes or advanced disease of any specific organ system.

Answer 38

1) Physiological - obvious from the history, but can be more difficult in older age 2) Psychiatric illness - features of anorexia nervosa, bulimia and affective disorders; alcoholic patients lose weight through self neglect and poor diet 3) Systemic diseases - chronic infections lead to weight loss and a history of recent travel, fever, night sweats, rigors, productive cough and dysuria must be sought. Sexual history is important. Weight loss is a late feature of disseminated malignancy 4) GI disease - dysphagia and gastric outlet obstruction cause defective intake. Malignancy may cause weight loss by mechanical obstruction, anorexia, or systemic effects. Malabsorption from pancreas or small bowel causes profound weight loss and nutritional deficiences. Crohn's and UC cause anorexia, fear of eating and loss of protein, blood and nutrients from the gut

Answer 39

Urinalysis for glucose, protein and blood Bloods - LFTs, random blood glucose, and TFTs, ESR Bone marrow aspirate or liver biopsy to identify cryptic miliary TB when there is strong clinical suspicion

Answer 40

This is infrequent passage of hard stools, often with straining, a sensation of incomplete evacuation and peri-anal or abdominal discomfort. It may be the end result of many disorders.

Answer 41

GI: - lack of dietary fibre - altered motility - e.g. irritable bowel syndrome - structural - e.g. colonic carcinoma, diverticular disease, Hirschsprungs disease - obstructed defacation - e.g. anal fissure, Crohn's disease Non GI: - drugs - e.g. opiates, anticholinergics - neurological - e.g. MS, paraplegia - metabolic/ endocrine - e.g. hypercalcaemia, hypothyroidism

Answer 42

In the absence of a history suggesting a specific cause it is not necessary to investigate every person with constipation. Most respond to dietary fibre supplementation and the judicious use of laxatives. Middle-aged or elderly patients with a short history or worrying symptoms (rectal bleeding, pain or weight loss) must be investigated promptly, by either barium enema or colonoscopy. Others should be investigated as follows: - initially DRE, proctoscopy, sigmoidoscopy, routine biochemistry to include Ca++ and TFTs - if normal, 1 month trial of supplementary fibre and/or laxatives - if symptoms persist, examination of the colon by barium enema or colonoscopy to look for structural disease

Answer 43

1) Visceral - usually midline, due to stretching or torsion of a viscus, poorly localised 2) Parietal - usually sharp, lateralised and localised due to peritoneal irritation 3) Referred - e.g. gallbladder pain referred to back or shoulder

Answer 44

One of the most common ways to think about the potential causes is the location of the pain. Sometimes patients present with generalised pain but probably the most common present is pain in a particular region of the abdomen. Some conditions characteristically cause central pain before localising to a particular area. A good example is appendicitis, which typically presents with central abdominal pain before localising to the right iliac fossa. RUQ - cholecystitis, cholangitis Epigastric - pancreatitis, peptic ulcer, gastritis Loin - renal colic, pyelonephritis Central - AAA, mesenteric ischaemia, small bowel obstruction Suprapubic - UTI, cystitis, retention, gynaecological pain RIF - Appendicitis, ectopic pregnancy

Answer 45

This depends on the underlying cause. Acute abdominal pain is usually the result of one of 3 pathological processes: 1) Inflammation (e.g. appendicitis, pancreatitis, diverticulitis) - diffuse pain develops gradually over hours. If the parietal peritoneum is involved, pain becomes localised. Movement exacerbates it; rigidity and guarding occur 2) Perforation (e.g. peptic ulcer, ovarian cyst, diverticular disease) - pain starts abruptly, is severe and leads to generalised peritonitis 3) Obstruction (e.g. intestinal, biliary or ureteric) - pain is colicky with spasms causing the patient to writhe around. If it does not dissappear between spasms, this suggests complicating inflammation

Answer 46

RUQ Caused by a gallstone getting lodged in the bile duct. Classically provoked by eating a fatty meal. In contrast to acute cholecystitis no fever and inflammatory markers are normal.

Answer 47

Inflammation/infection of the gallbladder secondary to impacted gallstones. Murphy's sign positive (arrest of inspiration on palpation of the RUQ). Fever and raised inflammatory markers.

Answer 48

Ascending cholangitis is a bacterial infection of the biliary tree. The most common predisposing factor is gallstones. Charcot's triad of right upper quadrant pain, fever and jaundice occurs in about 20-50% of patients.

Answer 49

Pain often in the epigastric region sometimes radiating to the back. Usually due to alcohol or gallstones. Pain is often very severe. Examination may reveal tenderness, ileus and low-grade fever

Answer 50

Pain is in the epigastrium. There may be a history of NSAID use or alcohol excess. Duodenal ulcers: more common than gastric ulcers, epigastric pain relieved by eating. Gastric ulcers: epigastric pain worsened by eating. Features of upper gastrointestinal haemorrhage may be seen (haematemesis, melena etc).

Answer 51

Pain initial in the central abdomen before localising to the right iliac fossa (RIF). Anorexia is common. Tachycardia, low-grade pyrexia, tenderness in RIF Rovsing's sign: more pain in RIF than LIF when palpating LIF.

Answer 52

Infection of existing large bowel diverticula. Colicky pain typically in the LLQ. Diarrhoea, sometimes bloody. Fever, raised inflammatory markers and white cells.

Answer 53

History of malignancy (intraluminal obstruction)/previous operations (adhesions). Vomiting. Not opened bowels recently. 'Tinkling' bowel sounds.

Answer 54

Loin pain radiating to groin. Pain is often severe but intermittent. Patient's are characteristically restless. Visible or non-visible haematuria may be present.

Answer 55

Loin pain + fever + rigors

Answer 56

Suprapubic region. Caused by obstruction to the bladder outflow. Much more common in men, who often have a history of benign prostatic hyperplasia.

Answer 57

Typically presents with pain in the right or left iliac fossa and a history of amenorrhoea for the past 6-9 weeks. Vaginal bleeding may be present.

Answer 58

Patients often have a history of atrial fibrillation or other cardiovascular disease. Diarrhoea, rectal bleeding may be seen. A metabolic acidosis is often seen (due to 'dying' tissue). Central abdominal pain.

Answer 59

A detailed history, including fever, weight loss and mood, is essential. If abdominal and rectal examination is normal, a careful search should be made for disease affecting the vertebral column, spinal cord, lungs and cardiovascular system. The choice of investigations depends on the history and examination. E.g. pain provoked by food in the presence of widespread atherosclerosis is likely to be mesenteric ischaemia and is best investigated using mesenteric anrgiography

Gastroenterology - Presenting problems Flashcards

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