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Gastrointestinal Flashcards

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1
Q

Briefly, what is a peptic ulcer?

A

A break in the epithelial lining of the stomach/duodenum which penetrates the muscularis mucosa.

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2
Q

What are the two main causes of/risk factors for peptic ulcers?

A
  1. Helicobacter pylori (H.pylori) infection

2. NSAIDs

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3
Q

Approximately what % of gastric and duodenal ulcers are caused by H.pylori infection? (2 individual %’s)

A

80% gastric

95% duodenal

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4
Q

How does H.pylori infection cause peptic ulcers?

A

It causes inflammation of the mucosal lining of the stomach, depleting the layer of alkaline mucus and altering gastric pH.

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5
Q

Approximately what % of gastric and duodenal ulcers are caused by NSAIDs?

A

20% gastric

5% duodenal

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6
Q

How do NSAIDs cause peptic ulcers?

A

They act by inhibiting prostaglandin synthesis, reducing the production of protective alkaline mucus and thereby increasing risk of ulceration, particularly in the stomach

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7
Q

What are the symptoms of a peptic ulcer/how does it present? (8)

A
  1. Upper/central abdominal pain described as burning or gnawing
  2. Difficulty breathing
  3. Dark stools
  4. Weight loss/anorexia - due to pain of eating
  5. Bloating
  6. Heart burn
  7. Nausea/vomiting
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8
Q

What may be the signs on examination with a peptic ulcer? (4)

A
  1. Tachycardia
  2. Hypotensive
  3. Melena
  4. Dyspnoea
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9
Q

What are the differential diagnoses with a peptic ulcer? (3)

A
  1. GORD
  2. Gastritis
  3. Hiatus hernia
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10
Q

How would a patient presenting with a suspected peptic ulcer be investigated?

A

Endoscopy

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11
Q

What treatments are available for the treatment of peptic ulcers?

A

PPI - to reduce gastric acid secretion

If caused by H.pylori infection, then treat with antibiotics; metronidazole or clarithromycin

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12
Q

What is Crohn’s disease?

A

A chronic relapsing-remitting non-infections inflammatory disease of the GI tract.

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13
Q

Which parts of the GI tract does Crohn’s affect, and which areas are most common?

A

Crohn’s can affect any part, from mouth to anus, but the inflammation is not continuous, so there will be ‘skip lesions’ - parts where the GI tract is unaffected.
The most common site is the terminal ileum, but can also affect the colon, ileocolon and upper GI tract.

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14
Q

Which layers of the GI tract are affected in Crohns?

A

All of them - it is a full thickness inflammation, compared to ulcerative colitis, which just affects the intestinal mucosa

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15
Q

What % of people with Crohn’s disease will have extra-intestinal manifestations?

A

35%

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16
Q

What are the extra-intestinal manifestations of Crohn’s disease related to disease activity?

A
  1. Pauci-articular arthritis (pauci indicates that fewer than 5 joints are affected at time of onset)
  2. Erythema nodosum
  3. Aphthous mouth ulcers
  4. Episcleritis
  5. Metabolic bone disease
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17
Q

What is pauci-articular arthritis?

A

It is a classification of juvenile rheumatoid arthritis in which fewer than 5 joints are affected, such as ankles, knees, wrists, hips, elbows and shoulders. It is usually asymmetric, acute and self-liiting (lasting for weeks) and joints tend not to be permanently damaged.

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18
Q

What is erythema nodosum?

A

Tender, red or violet subcutaneous nodules, normally 1-5cm in diameter. They are usually found on the anterior tibial area or extensor surfaces of the legs or arms

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19
Q

What is episcleritis?

A

Red eye with injected sclera and conjunctiva. It may be painless or painful with itching and burning

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20
Q

What are the three types of metabolic bone disease associated with Crohn’s?

A
  1. Osteopenia
  2. Osteoporosis
  3. Osteomalacia
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21
Q

What are the extra-intestinal manifestations of Crohn’s, not related to disease activity?

A
  1. Axial arthritis - this affects the sacroiliac joint and/or spine, causing buttock and back pain
  2. Polyarticular arthritis (usually symmetrical and persistent, damaging affected joints)
  3. Pyoderma gangrenosum
  4. Psoriasis
  5. Uveitis
  6. Hepatobilliary conditions
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22
Q

What is pyoderma gangrenosum?

A

Single or multiple erythematous papules or pustules develop into deep ulcers containing sterile, commonly occur on the shins and often at the site of previous trauma

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23
Q

What are the symptoms associated with uveitis?

A

Uveitis is usually bilateral, with an insidious onset and chronic course. It presents as a painful red eye, with injected conjunctiva, blurred vision, photophobia and headache

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24
Q

What are the hepatobilliary conditions associated with Crohn’s disease? (6)

A
  1. Primary sclerosing cholangitis
  2. Pericholangitis
  3. Steatosis
  4. Autoimmune hepatitis
  5. Cirrhosis
  6. Gallstones
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25
What are the risk factors associated with Crohn's disease?
1. Smoking 2. Family history 3. Infectious gastroenteritis 4. Appendicectomy 5. Drugs
26
What are the complications of Crohn's disease? (7)
1. Psychosocial impact - can hugely affect activities of daily living 2. Abscesses - in the intestinal wall and adjacent structures 3. Intestinal strictures - intestine narrows/completely obstructs the passage of bowel contents 4. Fistules - the bowel wall is perforated, allowing faecal matter into adjacent structures 5. Anaemia - due to iron, B12 and/or folate deficiency 6. Malnutrition 7. Colorectal/small bowel cancer
27
How might Crohn's disease present? what are the associated symptoms?
1. Otherwise unexplained persistent diarrhoea, including nocturnal diarrhoea 2. Abdominal pain/discomfort 3. Weight loss, faltering growth, delayed puberty 4. Non-specific symptoms such as fatigue, malaise, anorexia and fever
28
In suspected Crohn's disease, what may be seen on examination?
1. Pallor 2. Clubbing 3. Mouth ulcers 4. Abdominal tenderness or mass 5. Perianal pain or tenderness 6. Signs of malnutrition/malabsorption
29
What does a direct inguinal hernia protrude through?
A direct inguinal hernia arises from protrusion of abdominal viscera through a weakness of the posterior wall of the inguinal canal medial to the inferior epigastric vessels, specifically though the Hesselbach's triangle.
30
Where does indirect inguinal hernias arise from?
Indirect inguinal hernias arise through the deep ring and enter the inguinal canal. They arise lateral and superior to the course of the interior epigastric vessels, lateral to the Hesselbach triangle.
31
How do direct inguinal hernias occur?
They are generally acquired, and increase in incidence with age. They result from weakening of the transversalis fascia in the Hesselbach triangle
32
Who does direct inguinal hernias more commonly occur in?
The elderly with chronic conditions which increase intra-abdominal pressure over a long period, e.g. COPD, bladder outflow obstruction etc.
33
Are direct inguinal hernias normally uni- or bi- lateral? and why?
They are usually bilateral as they are caused by an increase in intra-abdominal pressure which will be transmitted to both side.
34
Are direct inguinal hernias susceptible to strangulation?
No, not compared to indirect, as they have wide neck.
35
On a CT scan, what sign is indicative of direct inguinal hernias?
A lateral crescent sign (lateral crescent of fat)
36
How many times more common are indirect inguinal hernias compared to direct inguinal hernias?
5 X more common
37
How many times more frequent are indirect inguinal hernias in males compared to females and why?
7 X more frequent/likely due to the persistence of the processus vaginalis during testicular descent
38
Do indirect inguinal hernias occur anterior or lateral to the hasselbach triangle?
Lateral to the hasselbach triangle
39
What is the route of an indirect inguinal hernia?
They enter the inguinal canal at the deep ring, lateral to the inferior epigastric vessels. It passes inferomedially to emerge via the superficial ring, and if large enough, extend into the scrotum
40
In females, how does an indirect inguinal hernia tend to pass?
They tend to follow the round ligament into the labia majora
41
What are the contents of an indirect inguinal hernia? (3)
1. Mesenteric fat (most common) 2. Small bowel loops 3. Mobile colon segments (sigmoid, caecum and appendix)
42
What are the 3 complications that can arise from indirect inguinal hernias?
1. Incarceration (most common - incidence can be as high as 30% in infants <2 months) 2. Strangulation with bowel ischaemia and perforation 3. Intestinal obstruction
43
What is a femoral hernia?
A femoral hernia is a type of groin herniation and compromises of a protrusion of a peritoneal sac through the femoral ring into the femoral canal, posterior and inferior to the inguinal ligament.
44
What may the peritoneal sac contain?
1. Preperitoneal fat 2. Omentum 3. Small bowel etc.
45
Which side do femoral hernias tend to occur more often on?
Right side
46
Are femoral hernias more common in males or females?
Females
47
What is the course of a femoral hernia?
Femoral hernias protrude inferior to the course of the inferior epigastric vessels and medial to the common femoral vein. They often have a narrow funnel-shaped neck and may compress the femoral vein, causing engorgement of distal collateral veins.
48
What is a De Garengeot hernia?
A femoral hernia containing an appendix
49
What causes GORD?
1. Defective lower-oesophageal sphincter 2. Hiatus hernia 3. Gastric outflow stenosis
50
What are the risk factors for GORD?
1. Smoking 2. Alcohol 3. Coffee and chocolate 4. High fatty food consumption (delay gastric emptying) 5. Drugs - CCB, benzodiazepines, nitrates
51
How does GORD tend to present?
Can present with heartburn (dyspepsia), a burning heaviness, or ache in the upper abdomen which is often related to eating. Other symptoms can include nausea, belching and a full feeling in the upper abdomen. The symptoms are often worse lying down and they can experience dysphagia (sensation of food being stuck).
52
How is GORD investigated?
Endoscopic examination - 10% have oesophagitis and 30% have negative reflux disease
53
Two treatments for GORD?
1. Alginate/Antacid - Peptac and Gaviscon | 2. PPI or H2-receptor antagonist
54
How does peptic ulcer present?
Epigastric pain, often related to hunger, specific foods, or time of day +/- bloating, fullness after meals, heartburn, tender epigastrium.
55
What are the ALARM Signs to look out for in suspected peptic ulcer?
``` A - anaemia (iron deficiency) L - Loss of weight A - anorexia R - recent onset symptoms M - melaena S - Swallowing difficulty / dysphagia ```
56
Why do NSAIDs cause ulcers?
Inhibit prostaglandin production, which therefore stops the production of a the protective alkaline mucus - thereby increasing the risk of ulceration
57
How does H.pylori cause ulcers?
It causes inflammation of the mucosal lining of the stomach, depleting the layer of alkaline mucus and altering the gastric pH. It also limits the action of somatostatin which regulates gastric acid secretion by parietal cells.
58
How do peptic ulcers typically present?
Epigastric pain, burning or gnawing, difficulty breathing, dark stools, bloating, heartburn, anorexia, nausea and vomiting.
59
Sign of peptic ulcer on examination?
1. Tachycardia 2. Hypotensive 3. Melena 4. Dyspnoea
60
Peptic ulcer investigation?
Endoscopy
61
Peptic ulcer treatment?
PPI | - treatment of H.pylori - metronidazole/clarithromycin
62
Acute GI bleeds, are defined as?
Upper GI bleed is a haemorrhage occurring at any point between the mouth and the duodenum. Lower GI bleed is a haemorrhage occurring at any point between the small intestine and the anus
63
Most common causes of GI bleeds?
1. Peptic ulcer disease | 2. Increasing use of warfarin, clopidogrel, aspirin and NSAIDs - all pose particular problems
64
What should be prescribed alongside NSAIDs if they are to be taken on a long-term plan?
PPIs
65
Upper GI bleeding causes are?
1. Peptic ulcer disease 2. H.pylori 3. NSAIDs 4. Gastritis 5. Oesophageal varices 6. Oesophagitis 7. Cancer 8. Inflammation of the GI lining from ingested materials 9. Malaria Weiss tear - bleeding from laceration at junction between stomach and oesophagus, normally caused by severe vomiting due to alcoholism or bulimia
66
Lower GI bleeding causes are?
1. Diverticular disease 2. GI cancer 3. IBD 4. Infectious diarrhoea 5. Angiodysplasia 6. Haemorrhoides 7. Anal fissures
67
How do GI bleeds present?
1. Vomiting of blood with ground coffee appearance 2. Tarry stools 3. Patients may go into shock 4. Symptoms of shock - hypotension, no urine output, tachycardia, LOC
68
How do you investigate GI bleeds?
Endoscopy
69
Treatment for GI bleeds?
Fluid resuscitation Surgical repair PPIs Endoscopic adrenaline injection
70
Why do gallstones occur?
Due to an imbalance in the chemical composition of bile which results precipitation of one of more of the constituents. Most common stone is cholesterol.
71
What are the different gallstones?
1. Cholesterol stone 2. Pigmented stone - dark coloured - made up of bilirubin and calcium salts 3. Mixed stone - mixture of above two
72
Risk factors for gallstones?
1. Obesity 2. Increasing age 3. Female 4. Diabetes 5. COCP/HRT 6. Smoking 7. Crohn's disease (five F's - fat, fertile, forty, female, fair)
73
Cholangitis is associated with charcot's triad, what is this?
URQ pain Fever Jaundice
74
Which form of hepatitis is endemic in low income countries?
Hep A - 1/4 of all acute infectious hepatitis cases in England
75
How is Hep A transmitted?
1. Close contract or via faecal-oral - contaminated water and food
76
Three phases to viral hepatitis?
1. Prodromal phase - (2 days - 2 weeks) includes flu-like symptoms, GI symptoms (nausea, RUQ pain) 2. Icteric phase (1 - 3 weeks) jaundice, pale stools and dark urine, pruritus, fatigue, anorexia, vomiting. 3. Convalescent phase (up to 6 months) includes malaise, anorexia, muscle weakness and hepatic tenderness
77
What are the investigations for suspected hepatitis?
- Laboratory IgM antibodies (serology testing) to Hep A | - ALT, AST, bilirubin - LFTs
78
Where is Hep B most common?
Hep B is most common in sub-saharan africa, most of Asia and the pacific islands.
79
What % of acute infectious hepatitis is caused by Hep B in England?
34%
80
How is Hep B most commonly spread?
By sexual contact or injecting drugs - transmission of blood
81
What are the prodromal symptoms of HepB?
Fever, arthralgia, rash
82
LFT results for hep B include?
Deranged LFTs - typically see ALT/AST reach levels of 1000-2000 IU/L (with ALT being high than AST) - commonly seen in chronic liver disease
83
Which investigation can determine if Hep B is the cause?
Hep B surface antigen (HBsAg) or Hep B core antigen
84
Hep C is most commonly caused by what?
Injecting drug use - 90%
85
What is the treatment for Crohn's disease? (4)
1. Corticosteroids - prednisolone (induce remission) 2. Immunosuppressants - thiopurines (1st line) or methotrexate - maintenance of remission 3. Biologic therapy - anti-tumour necrosis factor alpha monoclonal antibody agents infliximab 4. Aminosalicylates - mesalazine or sulfasalazine (when corticosteroids are contraindicated or not tolerated)
86
What is the tool to measure severity of UC?
Truelove and Witts severity index
87
What are the 6 categories/signs used in Truelove and Witts severity index?
1. Bowel movements per day 2. Blood in stools 3. Pyrexia 4. Tachycardia 5. Anaemia 6. Erythrocyte sedimentation rate
88
Treatment for UC?
Aminosalicylates and NSAIDs

Y3 Core Conditions (19 decks)

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