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GASTROINTESTINAL Flashcards

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1
Q

PEPTIC ULCER
How does NSAIDs cause ulcer formation?

A

Reduced prostaglandin synthesis due to salicylic acid release –> cell death –> no mucin production = no mucosal protection –> ulcer formation

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2
Q

PEPTIC ULCER
How does H. pylori cause ulcer formation?

A
  • causes decrease in HCO3- which increases acidity
  • H.pylori secretes urease
  • splits urea into CO2 and ammonia
  • ammonia + H+ forms ammonium which is toxic to gastric mucosa
  • Acute inflammatory reaction (neutrophils) with less mucosal defence
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3
Q

PEPTIC ULCER
what is the management of h.pylori?

A

7 day course of:
- PPI + amoxicillin + (clarithromycin or metronidazole)

if penicillin allergic
- PPI + metronidazole + clarithromycin

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4
Q

MALABSORPTION
Give 5 broad causes of malabsorption

A
  1. Defective intraluminal digestion
  2. Insufficient absorptive area
  3. Lack of digestive enzymes
  4. Defective epithelial transport
  5. Lymphatic obstruction
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5
Q

ULCERATIVE COLITIS
give 3 microscopic features that will be seen in ulcerative colitis

A
  1. Crypt abscess
  2. goblet cell depletion
  3. mucosal inflammation - does not go deeper
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6
Q

CROHNS DISEASE
What is the treatment for induction of remission for Crohn’s disease?

A

INDUCTION OF REMISSION
MILD (1st presentation/1 exacerbation in 1yr)
- 1st line = IV/PO steroid
- 2nd line = oral ASA (MESALAZINE)
- distal/ileocaecal disease = budesonide

MODERATE (>2 exacerbations in 1yr)
- 1st line = azathioprine or mercaptopurine
- 2nd line = methotrexate

SEVERE (unresponsive to conventional therapy)
- 1st line = infliximab or adalimumab (anti-TNF)
- 2nd line = other biological agents

REFRACTORY
- surgery

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7
Q

ULCERATIVE COLITIS
What is the treatment for induction of remission for Ulcerative colitis?

A

INDUCTION OF REMISSION
PROCTITIS
- 1st line = topical ASA (RECTAL MESALAZINE)
- 2nd line = topical ASA + oral ASA (oral MESALAZINE)
- 3rd line = oral ASA + oral corticosteroid

PROCTOSIGMOIDITIS/LEFT-SIDED UC
- 1st line = topical ASA
- 2nd line = topical ASA + high-dose oral ASA / high-dose oral ASA + topical corticosteroid
- 3rd line = oral ASA + oral corticosteroid

EXTENSIVE DISEASE
- 1st line = topical ASA + high-dose oral ASA
- 2nd line = oral ASA + oral corticosteroid

SEVERE DISEASE
- should be treated in hospital
- 1st line = IV steroids (IV ciclosporin if contraindicated)
- 2nd line = IV steroids + IV ciclosporin or consider surgery

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8
Q

ULCERATIVE COLITIS
Give 5 complications of Ulcerative colitis

A
  1. Colon –> blood loss, colorectal cancer, toxic dilatation
  2. Arthritis
  3. Iritis, episcleritis
  4. Fatty liver and primary sclerosing cholangitis
  5. Erythema nodosum
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9
Q

CROHNS DISEASE
Give 5 complications of Crohn’s

A

PERFORATION AND BLEEDING = MAJOR

  1. Malabsorption
  2. Obstruction –> toxic dilatation
  3. Fistula/abscess formation
  4. Anal skin tag/fissures/fistula
  5. Neoplasia
  6. Amyloidosis
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10
Q

COELIAC DISEASE
Describe the pathophysiology of Coeliac disease

A
  1. Gliadin from gluten deaminated by tissue transglutaminase –> increases immunogenicity
  2. Gliadin recognised by HLA-DQ2 receptor on APC –> inflammatory response
  3. Plasma cells produce anti-gliadin and tissue transglutaminase –> T cell/cytokine activated
  4. Villous atrophy and crypt hyperplasia –> malabsorption
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11
Q

COELIAC DISEASE
What 3 histological features are needed in order to make a diagnosis of coeliac disease?

A
  1. Raised intraepithelial lymphocytes
  2. Crypt hyperplasia
  3. Villous atrophy
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12
Q

COELIAC DISEASE
Give 3 complications of Coeliac disease

A
  1. Osteoporosis
  2. Anaemia
  3. Increased risk of GI tumours
  4. secondary lactose intolerance
  5. T-cell lymphoma
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13
Q

OESOPHAGEAL CANCER
Give 3 causes of squamous cell carcinoma

A
  1. Smoking
  2. Alcohol
  3. Poor diet/obesity
  4. coeliac disease
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14
Q

OESOPHAGEAL CANCER
Name 2 types of Oesophageal cancer

A
  1. Adenocarcinoma - distal 1/3rd of oesophagus

2. Squamous cell carcinoma - proximal 2/3rds of oesophagus

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15
Q

OESOPHAGEAL CANCER
What can cause oesophageal adenocarcinoma?

A

Barrett’s oesophagus

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16
Q

GASTRIC CANCER
Give 3 causes of gastric cancer

A
  1. Smoked foods
  2. Pickles
  3. H. pylori infection
  4. Pernicious anaemia
  5. Gastritis
  6. family history
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17
Q

GASTRIC CANCER
what are the red flag signs for upper GI cancer?

A

For people with an upper abdominal mass consistent with stomach cancer:

  • Dysphagia of any age
  • Aged ≥ 55yr + weight loss with any of the following:
  • Upper abdominal pain/(or)
  • Reflux/ (or)
  • Dyspepsia
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18
Q

GASTRIC CANCER
what may be seen in biopsy of gastric cancer?

A

signet ring cells (higher numbers = worse prognosis

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19
Q

EGORD
Name 3 extra oesophageal symptoms of GORD

A
  1. Nocturnal asthma
  2. Chronic cough
  3. Laryngitis
  4. Sinusitis
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20
Q

CROHNS DISEASE
what are the microscopic features of crohns disease?

A
  • transmural inflammation
  • granulomas
  • increase in inflammatory cells
  • goblet cells
  • less crypt abscesses
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21
Q

COELIAC DISEASE
what are the risk factors for coeliac disease?

A
  • HLA DQ2/DQ8
  • other autoimmune diseases e.g. T1DM, thyroid disease, Sjogren’s
  • IgA deficiency
  • breast feeding
  • age of introduction to gluten into diet
  • rotavirus infection in infancy
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22
Q

OESOPHAGEAL CANCER
what are the risk factors for oesophageal cancer?

A

ABCDEF

  • Achalasia
  • Barret’s oesophagus
  • Corrosive oesophagitis
  • Diverticulitis
  • oEsophageal web
  • Familial
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23
Q

MALLORY-WEISS TEAR
what are the investigations for mallory-weiss tears?

A

Rockall score (assess blood loss: <3 = low risk)
FBC, U&E, coag studies, group & save
ECG & cardiac enzymes

endoscopy to confirm tear

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24
Q

VARICES
what is the treatment for gastroesophageal varices?

A
  • ABCDE
  • Rockfall Score (Prediction of Rebleeding and Mortality)
  • Bleeding Varices - Terlipressin + Prophylactic Antibiotics (Ciprofloaxcin), Balloon tamponade (Sengstaken-Blakemore tube), Endoscopic Banding, TIPS
  • Bleed Prevention - BB + Endoscopic Banding. Cirrhosis = screening endoscopy
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25
IBS what is the rome III diagnostic criteria for IBS?
- recurrent abdominal pain at least 3 days a month in last 3 months - associated with 2 of following: - onset associated with change in frequency of stool - onset associated with change in form (appearance) of stool
26
DIVERTICULAR DISEASE what is the management for diverticulitis?
ANTIBIOTICS - 1st line = co-amoxiclav (if penicillin allergic = ciprofloxacin/metronidazole) ANALGESIA - paracetamol SUPPORTIVE - high fibre diet SURGERY
27
VOLVULUS what is the management for volvulus?
- endoscopic detorsion = rigid sigmoidoscopy and rectal tube - surgical intervention - fluid resuscitation - pain management
28
PHARYNGEAL POUCH where do pharyngeal pouches occur?
Posteromedial herniation between thyropharyngeus and cricopharyngeus muscles
29
BARRETTS OESOPHAGUS what is barrett's oesophagus?
Metaplasia of the lower esophageal mucosa (stratified squamous to columnar epithelium with goblet cells)
30
OESOPHAGEAL CANCER which are the most common types of oesophageal cancer in the developing and developed world?
developing = squamous cell carcinoma developed = adenocarcinoma
31
GORD what are the red flag symptoms for GORD that requires further investigation?
``` Dysphagia (difficulty swallowing) > 55yrs Weight loss Epigastric pain / reflux Treatment resistant dyspepsia Nausea and vomiting Anaemia Raised platelets ```
32
PEPTIC ULCERS what is the difference in presentation of gastric ulcers vs duodenal ulcers?
gastric ulcers = epigastric pain worse after eating, eased by antacids. haematemesis, weight loss, heart burn duodenal ulcers = epigastric pain before meals and at night, relieved by eating or milk. melaena, weight gain
33
DIVERTICULAR DISEASE what will imaging show in diverticulitis?
Imaging May Show Pneumoperitoneum Dilated Bowel Loops Obstruction Abscess
34
GASTRIC CANCER what are the 2 different types of gastric cancer?
type 1 = intestinal / differentiated (70-80%) - found in antrum and lesser curvature type 2 = diffuse / undifferentiated (20%) - found elsewhere
35
C.DIFF what is the treatment for c.diff?
1st line = vancomycin orally for 10 days 2nd line = oral fidaxomicin 3rd line = oral vancomycin +/- IV metronidazole
36
ISCHAEMIC COLITIS what are the risk factors for ischaemic colitis?
- age >60 - sex F>M - factor V Leiden - high cholesterol - reduced blood flow - HF, low BP, shock, DM, RA - previous abdominal surgery - heavy exercise - surgery on aorta
37
ISCHAEMIC COLITIS what are the investigations for ischaemic colitis?
colonoscopy = gold standard AXR - may show thumbprinting (due to mucosal oedema/haemorrhage)
38
ACHALASIA what are the investigations?
- oesophageal manometry (diagnostic) = excessive LOS tone - barium swallow = expanded oesophagus, fluid level (birds beak appearance) - CXR = wide mediastinum, fluid level
39
ACHALASIA what is the management?
- 1st line = pneumatic (balloon) dilation - heller cardiomyotomy (if recurrent or severe symptoms) - intra-sphincteric botox injection - drug therapy (nitrates, CCBs)
40
ANAL FISSURES what is the management?
ACUTE - high fibre diet + high fluid intake - laxatives (1st line = bulk-forming, 2nd line = lactulose) - lubricants - topical anaesthetic - analgesia CHRONIC - above techniques - 1st line = topical GTN - if GTN not effective after 8 weeks, refer for surgery (sphincterotomy) or botox
41
CONSTIPATION what is the management for short duration constipation (<3 months)?
1st line - lifestyle advice (increase fibre, increase exercise, fluid intake) - bulking laxative (ispaghula husk) 2nd line - if hard stool, difficult to pass = osmotic laxative (macrogol, lactulose) - if soft stool, inadequate emptying = stimulant laxatives (senna, bisacodyl)
42
CONSTIPATION what is the management for faecal impaction?
1st line = osmotic laxative (macrogol) +/- stimulant laxative (senna) 2nd line = suppository (bisacodyl/glycerol) 3rd line = enema (sodium phosphate)
43
HAEMORRHOIDS what is the dentate line?
divides the upper two-thirds of the anal canal from the lower third of the anal canal - upper two-thirds = rectal columnar epithelium - lower third = stratified squamous epithelium (highly innervated)
44
HAEMORRHOIDS what is the management?
LIFESTYLE - high fibre diet - adequate water intake - toilet training - analgesia (NSAIDs) - laxatives (bulk, stimulant, osmotic or softeners) MEDICAL - topical agents (anaesthetic + steroids) - venoactive agents - antispasmodic agents SURGERY - rubber band ligation - sclerotherapy - infrared coagulation - haemorrhoidectomy
45
HIATUS HERNIA what is the management?
LIFESTYLE - small frequent meals - stop smoking - avoid lying down after eating MEDICAL - PPI e.g. omeprazole SURGERY - laparoscopic repair - Nissen's fundoplication
46
MALNUTRITION what are the clinical features of zinc deficiency?
- delayed wound healing - impaired taste - hair loss - immune deficiency
47
MALNUTRITION what are the components of a MUST score?
- BMI - amount of unplanned weight loss in past 3-6 months - acute disease effect
48
MALNUTRITION what is the criteria for malnutrition?
any of the following: - BMI <18.5 - unintentional weight loss >10% in last 3-6 months - BMI <20 and unintentional weight loss >5% in last 3-6 months
49
ANAL FISTULA what are the different types according to the Parks classification?
- extrasphincteric = outside sphincter complex - suprasphincteric = runs over the top of the puborectalis - trans-sphincteric = passes through external sphincter - intersphincteric = rns through the intersphinteric plane
50
ANAL FISTULA how are the different types categorised?
- using Parks classification
51
ANAL FISTULA what are the risk factors?
- history of anorectal abscess - chronic diarrhoea - IBD (crohns) - prior anorectal surgery - hydradentitis suppurativa - diverticulitis
52
ANAL FISTULA what is the management?
CONSERVATIVE - sitz baths - analgesia for pain control MEDICAL (for crohns) - infliximab - if symptomatic = metronidazole SURGERY - seton technique - fistulotomy
53
MESENTERIC ISCHAEMIA what are the clinical features?
SYMPTOMS - abdominal pain - N+V - diarrhoea +/- rectal bleeding - fever - weight loss SIGNS - absence of bowel sounds (late sign) - epigastric bruit on auscultation - rectal bleeding on PR - hypotensive and tachycardic
54
MESENTERIC ISCHAEMIA what are the risk factors?
- older age - female - AF - atherosclerosis (HTN, smoking, hypercholesterolaemia, DM) - previous MI - hypercoagulable state - infective endocarditis - vasculitis - hypoperfusion
55
ABDOMINAL WALL HERNIAS where are inguinal hernias found?
above + medial to pubic tubercle
56
ABDOMINAL WALL HERNIAS where are femoral hernias found? why are they dangerous?
below + lateral to pubic tubercle (more common in women) are at high risk of strangulation
57
CROHN'S DISEASE what is the management for maintenance of remission in crohn's disease?
- 1st line = azathioprine or mercaptopurine - 2nd line = methotrexate - post surgery = consider azathioprine +/- methotrexate STOP SMOKING
58
ULCERATIVE COLITIS what is the management for the maintenance of remission in UC?
MILD-MODERATE - proctitis + rectosigmoid = topical ASA / topical ASA + oral ASA / oral ASA - left-sided + extensive = low dose oral ASA SEVERE (severe exacerbation or >2 exacerbations - oral azathioprine or oral mercaptopurine
59
GIARDIASIS what are the risk factors?
- foreign travel - swimming/drinking water from a river or lake - male-male sexual contact
60
GIARDIASIS what are the clinical features?
- often asymptomatic - non-bloody diarrhoea - steatorrhea - bloating - abdominal pain - lethargy - flatulence - weight loss - malabsorption and lactose intolerance can occur
61
GIARDIASIS what are the investigations?
- stool microscopy for trophozoite and cysts - stool antigen detection test
62
GIARDIASIS what is the management?
metronidazole
63
BACTERIAL GASTROENTERITIS what is the typical presentation of e.coli infection?
- common amongst travellers - watery stools - abdominal cramps and nausea
64
BACTERIAL GASTROENTERITIS what is the typical presentation of staph aureus infection?
- severe vomiting - short incubation period
65
BACTERIAL GASTROENTERITIS what is the typical presentation of campylobacter?
- flu-like prodrome followed by crampy abdominal pains, fever and diarrhoea which may be bloody - may mimic appendicitis
66
BACTERIAL GASTROENTERITIS what is the typical presentation of b.cereus infection?
two types of illness are seen - vomiting within 6 hrs - diarrhoeal illness occurring after 6 hrs
67
BACTERIAL GASTROENTERITIS what is the most common cause of travellers diarrhoea?
e.coli
68
BACTERIAL GASTROENTERITIS what are the most common causes of acute food poisoning?
- s.aureus - b.cereus - clostridium perfringens
69
IBD what should you test before starting treatment with azathioprine or mercaptopurine?
+ TPMT activity
70
UPPER GI BLEED when is Glasgow-Blatchford scoring system used?
risk assessment before endoscopy to help decide if a patient can be managed as an outpatient
71
UPPER GI BLEED what would a Glasgow-Blatchford score of 0 mean?
may be considered for early discharge
72
UPPER GI BLEED when is Rockall score used?
after endoscopy to calculate risk of rebleeding and mortality
73
UPPER GI BLEED what is the management of a variceal bleed?
terlipressin prophylactic antibiotics (ciprofloxacin) endoscopy band ligation TIPS
74
UPPER GI BLEED what is the management of non-variceal bleed?
PPI after endoscopy
75
ANAL CANCER what is the biggest risk factor?
HPV infection
76
RECTAL CANCER what is the most common histological type?
adenocarcinoma
77
RECTAL CANCER what blood marker can be used to monitor response to treatment?
carcinoembryonic antigen (CEA)

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