Gastrointestinal

Question 1

Define CONSTIPATION.

Answer 1

Constipation is the passage of hard and small stools.

N.B. it is more important to consider the consistency of stools, rather than the frequency of passage. A person who passes hard, small, pellet-like stools every day is more likely to be constipated than a person who passes soft, bulky stools only 2 - 3 times per week.

Question 2

How is constipation diagnosed according to the ROME III CRITERIA?

Answer 2

According to the Rome III Criteria, two of the following must be present for at least 12 weeks:
✔️ reduced stool production (<3 times per week)
✔️ passage of hard or lumpy stools > 25% of the time
✔️ frequent straining >25% of the time
✔️ sensation of incomplete emptying >25% of the time
✔️ use of manual manoeuvres > 25% of the time
✔️ sensation of anorectal obstruction >25% of the time

Question 3

What are some differential diagnoses for CONSTIPATION?

Answer 3

Psychogenic Causes
✔️ depression / anxiety 
✔️ stress
✔️ anorexia nervosa 
✔️ irritable bowel syndrome (IBS)

Neurological Causes
✔️ autonomic neuropathy (e.g. diabetes mellitus)
✔️ Parkinson Disease
✔️ spinal cord injury / compression
✔️ CVA
✔️ Cauda Equina Syndrome

Endocrine / Metabolic Causes
✔️ hypothyroidism
✔️ hypokalaemia

Gastrointestinal Conditions
✔️ small or large bowel obstruction
✔️ diverticular disease
✔️ malignancy (external or internal compression)
✔️ inflammatory bowel disease
✔️ anorectal fissures

Drugs
✔️ opioids
✔️ anticholinergic medications
✔️ iron supplementation

Other
✔️ nutritional discrepancies (e.g. inadequate fibre)

Question 4

Red flag symptoms for CONSTIPATION?

Answer 4

✔️ unexplained fever or weight loss
✔️ acute onset in a patient > 40 years
✔️ personal or family history of bowel cancer
✔️ blood in stools

Question 5

Appropriate investigations for CONSTIPATION?

Answer 5

Bedside Ix
✔️ stool sample + MCS
✔️ FOBT

Laboratory Ix
✔️ FBC + WCC
✔️ Inflammatory markers
✔️ UECs
✔️ eLFTs
✔️ coags
✔️ fasting lipids
✔️ TFTs
✔️ Iron Studies, B12 + folate

Imaging Ix
✔️ abdominal X ray
✔️ abdomina CT scan
✔️ colonoscopy +/- endoscopy

Question 6

Define DIARRHEA.

Answer 6

Diarrhoea is defined as increased frequency of defecation.

There are four categories / subtypes of diarrhoea:

1. acute watery diarrhoea
2. acute bloody diarrhoea
3. chronic diarrhoea
4. steatorrhea

Question 7

Outline differential diagnoses for DIARRHOEA.

Answer 7

PROBABILITY DIAGNOSIS
✔️ acute diarrhoea –> viral gastroenteritis, drugs, antibiotic use, IBS, dietary indiscretion
✔️ chronic diarrhoea –> IBS, Coeliac Disease, drugs, infection

RED FLAG DIAGNOSES
✔️ malignancy
✔️ IBD (Crohn’s Disease, Ulcerative Colitis)
✔️ pseudomembranous colitis
✔️ serious infections (e.g. cholera, typhoid, malaria, haemorrhagic E. Coli)

OFTEN MISSED
✔️ Coeliac Disease
✔️ lactose intolerance
✔️ diverticulitis 
✔️ ischemic colitis
✔️ carcinoid tumours
✔️ giardia infection
✔️ cytomegalovirus infection

MASQUERADES
✔️ diabetes mellitus
✔️ drugs (e.g. cholinergic agents, motility agents)
✔️ depression
✔️ thyroid disorders (e.g. hyperthyroidism)
✔️ anaemia
✔️ spinal dysfunction (e.g. cauda equina syndrome)
✔️ UTI

Question 8

Red flag symptoms for DIARRHOEA?

Answer 8

✔️ recent unexplained weight loss
✔️ unexplained fever
✔️ recent overseas travel
✔️ personal or family Hx of bowel cancer
✔️ severe abdominal pain

Question 9

Appropriate investigations for DIARRHOEA?

Answer 9

Bedside Ix
✔️ stool sample + MCS
✔️ urine dipstick
✔️ ABG (elevated lactate in the case of ischemic colitis)

Laboratory Ix
✔️ FBC + WCC
✔️ Inflammatory markers
✔️ UECs
✔️ eLFTs
✔️ coags
✔️ fasting lipids
✔️ TFTs
✔️ Iron Studies, B12 + folate

Imaging Ix
✔️ abdominal X ray
✔️ abdomina CT scan
✔️ colonoscopy +/- endoscopy

Question 10

Outline some causes for MALABSORPTION?

What are the clinical features of malabsorption?

Answer 10

✔️ Coeliac Disease
✔️ Crohn's Disease
✔️ Tropical Sprue / Whipple's Disease
✔️ Pancreatic insufficiency
✔️ Lymphoma 
✔️ Gastrectomy 

Clinical features include: 
✔️ thick, bulky and pale stools
✔️ difficult to flush
✔️ weight loss / failure to thrive
✔️ anaemia
✔️ signs of other vitamin deficiencies

Question 11

What are the three most common causes for DYSPHAGIA?

Answer 11

1. Oesophgeal stricture (secondary to GORD)
2. Carcinoma
3. Achalasia

Question 12

Outline Ddx for DYSPHAGIA

Answer 12

STRUCTURAL CAUSES
✔️ oesophageal webbing (secondary to IDA)
✔️ stricture (secondary to GORD)
✔️ foreign body
✔️ oesophageal malignancy
✔️ external compressing malignancy
✔️ goitre

NB. Dysphagia for solids only is suggestive of an structural cause

FUNCTIONAL CAUSES
✔️ achalasia
✔️ CVA
✔️ Parkinsons' Disease
✔️ MND
✔️ myasthenia gravis

NB. dysphagia for solids and liquids + intermittent / fluctuating symptoms is suggestive of a functional cause

Question 13

What are RED FLAG symptoms for DYSPHAGIA?

Answer 13

✔️ patient > 50 years of age
✔️ progressive dysphagia
✔️dysphagia to solids
✔️ unexplained weight loss, fever, fatigue etc.
✔️ hoarseness of the voice
✔️ painful swallowing
✔️ neurological signs and symptoms

Question 14

Complications of long-term PPI use?

Answer 14

✔️ B12 + folate deficiency (leading to megaloblastic anaemia)
✔️ iron deficiency anaemia
✔️ hyopmagnessemia and hypocalcemia (leading to increased risk of osteoporosis and fractures)
✔️ increased risk of pneumonia
✔️ increased risk of C. difficle infection

Question 15

Outline the appropriate management for MILD GORD.

Answer 15

MILD GORD = < 1 episode per week

Lifestyle modifications:
✔️ weight reduction
✔️ avoid eating < 2 - 3 hours prior to sleep
✔️ sleep with head propped up on pillow
✔️ smoking cessation
✔️ alcohol and caffeine reduction
✔️ avoid eating 2 - 3 hours after vigorous exercise

“On demand…” medical therapy:
✔️ antacids
✔️ H2 receptor antagonists
✔️ proton pump inhibitors (e.g. esomeprazole 20mg PO, 30 to 60 mins before meal)

Question 16

Outline the appropriate management for MODERATE to SEVERE GORD.

Answer 16

PPI Therapy - Initial Therapy
✔️ esomeprazole 20mg PO, 30 to 60 mins before meal
✔️ continue initial therapy for 4 - 8 weeks, or until symptoms are under control
✔️ once symptoms have been controlled, begin to titrate down the dose (e.g. one tablet every 2 days for one week, followed by one tablet every 3 days for one week etc.)

Maintenance Therapy
✔️ if PPIs are appropriate in controlling patient symptoms, the patient should be continued on PPI therapy at the lowest dose possible for symptom relief
✔️ review the need and appropriateness of PPI therapy regularly
✔️ titrate down dose as appropriate

Question 17

Risk factors for GORD?

Answer 17

✔️ male gender
✔️ obesity / high BMI
✔️ pregnancy
✔️ smoking
✔️ alcohol + caffeine consumption 
✔️ sclerodema
✔️ sliding hiatus hernia

Question 18

Risk factors for peptic ulcer disease?

Answer 18

✔️ chronic gastritis
✔️ chronic NSAID use
✔️ H. pylori infection (occurs in ~50% of the adult population
✔️ chronic corticosteroid / glucocorticoid use
✔️ Zollinger Ellison syndrome
✔️ stress
✔️ SSRIs
✔️ smoking, alcohol, caffeine consumption

Question 19

Describe the clinical presentation of PUD for gastric ulcers as opposed to duodenal ulcers.

Answer 19

GASTRIC ULCERS
✔️ pain comes on 1 - 2 hours after eating (immediate)
✔️ pain absent with bowel rest
✔️ history of weight loss (due to reduced food intake as a result of fear for pain)
✔️ relief with antacids
✔️ +ve occult stool test
✔️ nocturnal pain in 30 to 40% of patients

DUODENAL ULCERS
✔️ pain comes on 3 - 4 hours after eating (delayed)
✔️ pain is present with bowel rest
✔️ history of weight gain (increased food intake as this improves / alleviates symptoms)
✔️ relief with antacids
✔️ +ve occult stool test
✔️ nocturnal pain in 40 to 80% of patients

Question 20

What is the appropriate management for H. pylori infection?

Answer 20

TRIPLE THERAPY!!

1. esomeprazole 20mg PO, once daily for 7 days
2. amoxicillin 1g PO, once daily for 7 days
3. clarithromycin 500mg PO, once daily for 7 days

Following completion of treatment it is imperative to retest for the presence of H. pylori via the urease breath test.

Question 21

What is the appropriate management for an NSAID induced PUD?

Answer 21

Cease the NSAID and treat with PPI (e.g. esomeprazole) for 8 to 12 weeks.

Question 22

What is the pathophysiology of DIVERTICULITIS?

Answer 22

Diverticular disease is the formation of diverticulum within the colon (usually the descending colon). Diverticulitis is overlying infection that can come about when faeces or food become impacted in these outpouchings.

Chronic constipation contributes to increased intraluminal pressure. Increased pressure can force areas of mucosa to penetrate into the smooth muscle layer of the bowel. This is particularly common at natural areas of weakening (e.g. vasa recta within the circular muscle layer). This is the formation of diverticulum, and is typically asymptomatic.

Continued increased pressure can force faeces or food particles into the diverticulum. If these become infected, inflammation causes the symptoms of diverticulitis.

Question 23

Outline the key symptoms of DIVERTICULITIS.

Answer 23

✔️ LIF pain and tenderness
✔️ alternating cramping and diarrhoea
✔️ nausea and vomiting
✔️ blood in stools
✔️ fever, chills and rigours (if systemically unwell)
✔️ urinary symptoms (due to adjacent inflammation)

Question 24

Outline management of complicated versus uncomplicated diverticular disease.

Answer 24

UNCOMPLICATED DIVERTICULAR DISEASE
Lifestyle modifications include:
✔️ gradually increase more fibre into the diet
✔️ use of laxatives to relive constipation
✔️ weight loss (if appropriate)
✔️ increased physical activity
✔️ increased fluid consumption

Antibiotic therapy may be appropriate if there are signs of uncomplicated diverticulitis (contrast CT to confirm). If this is the case, oral antibiotics should be prescribed –> amoxicillin + clavulanate (or trimethoprim + sulfamethoxazole if penicillin allergy)

COMPLICATED DIVERTICULAR DISEASE
In the case of complicated diverticular disease (e.g. perforation, peritonitis, obstruction), IV antibiotics are imperative.

A three-drug regime is necessary:

1. gentamycin
2. metronidazole
3. amoxicillin

Surgical intervention may be required.

Question 25

What is the ROME III CRITERIA for irritable bowel syndrome (IBS)?

Answer 25

In the last three months, the patient has experienced abdominal pain and discomfort on at least three days per month PLUS at least two of the following:

1. pain relieved by defecation
2. change to stool frequency
3. change to stool consistency

Question 26

What are some RED FLAG symptoms that refute the diagnosis of IBS?

Answer 26

✔️ patient age > 50 years
✔️ unexplained fever or weight loss
✔️ blood in stools
✔️ anaemia
✔️ pain waking the patient at night
✔️ recurrent vomiting
✔️ major change to baseline symptoms
✔️mouth ulcers
✔️ increased ESR / CRP
✔️ family history of IBD or CRC

Question 27

How is IBS diagnosed and managed?

Answer 27

IBS is a diagnosis of exclusion. All other possible diagnoses should be explored and investigated appropriately: 
✔️ stool sample + MCS
✔️ FBC + WCC
✔️ Inflammatory markers
✔️ UECs + eLFTs
✔️ fasting lipids
✔️ iron studies + B12 and folate
✔️ colonoscopy +/- upper endoscopy

Management is via FODMAP diet. Elimination of fermentable foods with gradual reintroduction of non-fibrous, fermentable alternatives.

Question 28

Outline key symptoms of IBS.

Answer 28

✔️ alternating constipation and diarrhoea
✔️ crampy abdominal pain, usually located centrally or in the iliac fossa
✔️ diarrhoea worse in the mornings; explosive diarrhoea with urgency
✔️ bloating, abdominal distension, gurgling of the stomach
✔️ fatigue and tiredness