Gastrointestinal H Yield Flashcards
Pathophysiology GORD
Gastro-oesophageal reflux disease (GORD) may be defined as symptoms of oesophagitis secondary to refluxed gastric contents
- Stomach acid flows through the lower oesophageal sphincter and into oesophagus, where it irritates the lining and causes symptoms.
- Oesophagus = squamous epithelial lining Stomach = columnar epithelial lining
- Squamous more sensitive to acid than columnar.
Triggers
- Greasy and spicy foods
- Coffee and tea
- Alcohol
- Non-steroidal anti-inflammatory drugs
- Stress
- Smoking
- Obesity
- Hiatus hernia
Presentation of GORD
- Heartburn
- Acid regurgitation
- Retrosternal or epigastric pain
- Bloating
- Nocturnal cough
- Hoarse voice
- Dyspepsia
Red Flags in patient’s presenting with GORD
two week wait referral for further investigation
- Dysphagia (difficulty swallowing) at any age gets an immediate two week wait referral
- Aged over 55 (this is generally the cut-off for urgent versus routine referrals)
- Weight loss
- Upper abdominal pain
- Reflux
- Treatment-resistant dyspepsia
- Nausea and vomiting
- Upper abdominal mass on palpation
- Low haemoglobin (anaemia)
- Raised platelet count
Different causes of Dysphagia
Detected using oesophago-gastro-duodenoscopy (OGD) (ENDOSCOPY)
- Oesophageal Cancer
- Oesophagitis - Inflammed Oesophagus
- Oesophageal candidiasis - often caused by steroid inhalers or HIV +ve
- Achalasia - oesophageal sphincter contraction (increased pressure) - food can’t pass to stomach
- Pharyngeal pouch - Sac which can develop between the lower part of the pharynx + upper oesophagus
- Systemic sclerosis - Oesphageal sphincter decreased pressure. - Dysmotility
- Myasthenia Gravis
- Globus hystericus - anxiety related?
Pharyngeal pouch: posteromedial herniation - often presents as dysphagia, regurgitation, aspiration, chronic cough & halitosis
GORD Investigations & Management
- Investigate with Endoscopy if Red flags
- Lifestyle Changes
- Medication Review - NSAIDs
Short Term
- Antacids - Gaviscon
Long term
- Full dose PPI 1m - then reduce dose if better - Omeprazole
- If not resolving then Double dose PPI 1m
- Consider H2Receptor Anatagonists - Ranitidine
24-hr oesophageal pH monitoring (gold standard test for diagnosis)
Surgery for reflux is called laparoscopic fundoplication. This involves tying the fundus of the stomach around the lower oesophagus to narrow the lower oesophageal sphincter.
What is Hiatus Hernia and its types
4 types
Management?
Herniation of the stomach up through the diaphragm
Type 1: Sliding - 95% - stomach slides up through the diaphragm, with the gastro-oesophageal junction passing up into the thorax.
Type 2: Rolling - Other part of stomach such as fundus ends up in thorax
Type 3: Sliding & Rolling
Type 4: Additional Organs enter thorax.
RF: Obesity, multiparity, other abdo pressures
Ix: Barium swallow is the most sensitive test.
Usually coinicidental find on OGD
Tx: Weight loss, PPI and in some rare cases surgery
What is H. Pylori & its investigations
Gram -ve bacteria which causes gastrointestinal problems.
- Bacteria damages epithelial lining -> Gastritis + Ulcers (Increased risk of cancer)
- Using Flagella to propel it self into gastric mucosa producing NH3- - protecting itself from Acid as NH3- alkalizes it.
- Toxins (cagA toxin) and NH3- from HPylori damage gastric mucosa
Investigations:
- Urea Breath test - Mass Spec of breath after consuming isotope C-13 - avoid if abx treatment within 4wk or PPi treatment within 2wk
- Rapid Urease Tests - CLO - Biopsy test
- Serum antibody - Oft stays +ve even after eradication
- Gastric Culture - to see if there’s any Abx sensitivity
- Stool Antigen test
Management of H Pylori
- 7 day treatment with
1.) PPI - Omeprazole
2.) Abx - Amoxicillin
3.) Abx - Clarithromycin or Metronidazole
If Allergic to Penicillin
1.) Omeprazole
2.) Clarithromycin
3.) Metronidazole
Zollinger–Ellison Syndrome
Definition, Features, Diagnosis, Management
- Excessive levels of Gastrin 2ndry to Gastrin-secreting tumour - often found in first part of duodenum as well as pancreas
- Gastrin produces excessive acid in this case
- Association with MEN Type I syndrome (AD genetic condition)
- Features: Dyspepsia, Diarrhoea, multiple gastroduodenal ulcers, malabsorption.
- Diagnosis: Fasting Gastrin Level
- Management: PPIs
What is Barret’s Oesophagus and its management
premalignant condition
- The lower oesophageal epithelium changes from squamous to columnar epithelium by metaplasia
- Risk factor for developing oesophageal adenocarcinoma
- More common in Males (7:1), Obese and Smokers
- Often seen by chance on OGD for dyspepsia
Treatment
- High dose PPI
- Endoscopic Monitioring with biopsy to see if it develops in to an Adenocarcinoma - 3-5y
- Ablation can be used to destroy abnormal columnar epithelial cells, which are then replaced with normal squamous epithelial cells. Ablation has a role in treating low and high-grade dysplasia to reduce cancer risk.
Diagnosis IBS
IBS is a functional disorder - no identifiable cause
IBS occurs in up to 20% of the population. It affects women more than men and is more common in younger adults.
6 month history of
* Abdominal Pain
* Bloating and/or
* Change in Bowel habit (diarrhoea &/or constipation)
Other Symptoms
- Mucus
- incomplete evacuation
IBS C= Constipation IBS D = Diarrhoea sometimes both interchangeable
Red flags:
* rectal bleeding
* unexplained/unintentional weight loss
* family history of bowel or ovarian cancer
* onset after 60 years of age
Management of IBS
Pharma & Dietary
Suggested primary care investigations are:
* full blood count - Anaemia
* ESR/CRP
* coeliac disease screen (tissue transglutaminase antibodies)
* Faecal calprotectin for inflammatory bowel disease
* CA125 for ovarian cancer
First Line
Pain: antispasmodic agents ( mebeverine, alverine, hyoscine butylbromide)
Constipation: Bulk forming laxatives but avoid lactulose - can cause bloating
Diarrhoea: Loperamide
No response to conventional laxatives: Linaclotide
Second-line pharmacological treatment
low-dose tricyclic antidepressants (e.g. amitriptyline 5-10 mg) are used in preference to selective serotonin reuptake inhibitors
Third Line
Consider CBT if symptoms over 12m
Dietary
- Consider Low FODMAP foods with dietician
- 12wk trial of Probiotics
- Regular meals, avoid large gaps
- Regular excercise
- Regularly Drink Water
- Avoid Caffiene, fizzy drinks and Alcohol
- More fibre if predominantly constipated, (less with diarrhoea/bloating)
- Diarrhoea, avoid sorbitol
- Wind and bloating consider increasing intake of oats (for example, oat-based breakfast cereal or porridge) and linseeds (up to one tablespoon per day).
- Limit Fresh Fruit x3 daily
Crohn’s Disease Features
Inflammatory Bowel Disease
- Commonly affects the terminal ileum and colon but may be seen anywhere from the mouth to anus.
- Cause is unknown but there is a strong genetic susceptibility
- Transmural Inflammation - so all layers to serosa inflamed
- This is why patients with Crohn’s are prone to strictures, fistulas and adhesions
- Present in 20s
Symptoms
- Weight loss lethargy
- Bloodless Diarrhoea (crohn’s colitis may cause bleed)
- Abdominal Pain (RLQ)
- Perianal Disease - Tags or ulcers.
- No mucus in faeces
- Smoking is a RF
Most patients: ileum affected,
Crohn’s Disease Investigations
- Raised CRP
- Faecal calprotectin 90% sensitive and specific for IBD. It is used as an initial test before moving on to endoscopy.
- Endoscopy (investigation of choice) - Skip Leisions + deep ulcers
- Histology: Goblet Cells, Granulomas, Inflammation in all layers
- Small Bowel Enema (used for terminal ileum): Rose thorn ulcers, strictures: showing Kantor’s string sign, fistulae.
Crohn’s Disease Management
Stop Smoking
Inducing Remission
* Prednislone or IV hydrocortisone
* Enteral nutrition - if concerns with steroids affecting growth in kids
* 2nd line: mesalazine - but not as affective
* can add azathioptrine or mercaptopurine to help induce
Maintaining Remision
* Azathioprine or mercaptopurine is used first-line to maintain remission
* Methotrexate Second line
Surgery
* Resecting the terminal ileum - ileocaecal resection
* Treating strictures - stricturoplasty
* Treating (perianal) fistulas - MRI is the investigation of choice for suspected perianal fistulae - give metronidazole & if perianal abscess then drain
* Draining seton used for complicated fistulas
assess TPMT activity before offering azathioprine or mercaptopurine
CD Risk
- Small Bowel Cancer
- Colorectal Cancer
- Osteoporosis
What is Enteral nutrition and how does it induce remission?
Enteral nutrition involves a specially formulated liquid diet given orally or by NG feed that replaces the patient’s diet. This induces remission by:
- Treating nutritional deficiencies
- Improving the gut microbiome
- Removing inflammatory foods
Ulcerative Colitis Features
- Inflammation always starts at rectum (most common site)
- Continous inflammation - not deep like CD - never beyond ileocaecal valve.
- Limited to large colon + rectum
- Smoking may be protective
Symptoms
* Bloody Diarrhoea
* short intervals between bouts
* Tenesmus - Urge to go toilet even when not required
* Abdominal Pain - LLQ
incidence: ages 15-25 years and in those aged 55-65 years.
Ulcerative Colitis Investigations
- Raised CRP
- Faecal calprotectin 90% sensitive and specific for IBD. It is used as an initial test before moving on to endoscopy.
- Endoscopy + biopsy - avoided in severe colitis due to risk of perforation
- Opt for flexible sigmoidoscopy: Red Mucosa, Bleeds eaily, submucosal inflammation only, widespread ulceration with preservation of adjacent mucosa (polyps), crypt abscesses & depletion of goblet cells
- Barium Enema: Loss of Haustrations, Pseudopolyps, narrow and short colon
Classifying Severity of UC
Mild Moderate & Severe
- mild: < 4 stools/day, only a small amount of blood
- moderate: 4-6 stools/day, varying amounts of blood, no systemic upset
- severe: >6 bloody stools per day + features of systemic upset (pyrexia, tachycardia, anaemia, raised inflammatory markers)
Ulcerative Colitis Management
Including Flare ups which can be caused by NSAIDs + Abx + stop smoking
Mild - Moderate
Severe
Remission
Mild - Moderate
- Proctitis - Rectal Mesalazine (aminosalicylate) - 2nd line Oral aminosalicylate.
- Proctosigmoiditis & left-sided ulcerative colitis - Rectal Mesalazine (aminosalicylate) - 2nd line + Oral aminosalicylate.
- Extensive Disease - Oral + Rectal aminosalicylate
Severe Colitis
- Treat in Hospital - IV steroids.intravenous ciclosporin may be used if steroid are contraindicated (consider surgery >72h)
Remission
- Oral aminosalicylate - mesalazine
Flare up
- Increase dosage of aminosalicylate - use more intermittently
- Severe relapse then oral azathioprine or oral mercaptopurine
avoid methotrexate in UC
Ulcerative colitis typically only affects the large bowel and rectum. Therefore, removing the entire large bowel and rectum (panproctocolectomy) will remove the disease. The patient has either a permanent ileostomy or an ileo-anal anastomosis (J-pouch).
An ileostomy is where the end portion of the small bowel (ileum) is brought onto the skin with a spout that drains stools directly into a tightly fitting stoma bag.
A J-pouch is where the ileum (small bowel) is folded back on itself and fashioned into a larger pouch, which is attached to the anus and functions like a rectum, collecting stools before the person opens their bowels.
Associated Symptoms with IBD
Crohns & Ulcerative Colitis
- Arthritis: inflammatory
- Erythema Nodusum (tender, red nodules on the shins caused by inflammation of the subcutaneous fat)
- Episcleritis (more common in Crohns)
- Uveitis (more common in UC)
- Osteoporosis
- Pyoderma gangrenosum - rapidly enlarging, painful skin ulcers
- Clubbing
- Primary sclerosing cholangitis (common in UC)
Coeliac Disease Features
autoimmune condition triggered by eating gluten
- It is strongly associated with HLA-DQ2 & HLA-DQ8
- Intermittent diarrhoea w/cramping
- fatigue
- smelly, floating faeces
- Wt loss, Anaemia
Complications
- Folate B9 Deficiency
- Osteoporosis, Osteomalacia,
- Hyposplenism
- Subfertility
Coeliac disease is associated with iron, folate and vitamin B12 deficiency
Repeated exposure leads to villous atrophy which in turn causes malabsorption.
Coeliac Disease Investigations
- Stop Gluten free diet for 6m
- TTG IgA Raised - First choice in NICE
- Endomyseal IgA Raised
Gold Standard
- Dudodenal or Jejunal Biopsy
- Villous Atrophy
- Crypt Hyperplasia
- More Lymphocytes
- Lamina propria infiltration
Coeliac disease increases the risk of developing enteropathy-associated T cell lymphoma
Coeliac Disease Management
- Gluten Free Diet: Wheat (Bread, Pasta, Pastry), Barley Beer, Rye, Oats
- Due to functional hyposplenism
Vaccination against Pneumococcal infection given and booster every 5 years
Some notable foods which are gluten-free include:
* rice
* potatoes
* corn (maize)
Appendicitis
most common in young people aged 10-20 years.
lymphoid hyperplasia or a faecolith → obstruction of appendiceal lumen → gut organisms invading the appendix wall → oedema, ischaemia +/- perforation
- Abdominal pain from umbilicus to RLQ (RIF) - peritoneal inflammation.
- Singular episode of Vomit
- Pyrexic
- anorexia is common
- Rebound tenderness on examination
- Rovsing’s: palpate LIF = pain in RIF
Diagnosis
- neutrophil-predominant leucocytosis seen
- Urinalysis to excl. pregnancy & uti etc.
- USS if not diagnosed clinically
Management
- Laprascopic Appendicectomy
- Prophylactic IV Abx given.
Peptic Ulcer
Duodenal & Gastric
Peptic ulcers involve ulceration of the mucosa of the stomach (gastric ulcer) or the proximal duodenum (duodenal ulcer). Duodenal ulcers are more common.
Symptoms
- Epigastric Pain
- N&V
- Dyspepsia
- Haematamesis (vomit blood)
- Coffee Ground Vomit
- Malena (Dark Stools)
- Low Hb
Gastic Vs Duodenal
- Gastric = pain w/eating (overall lose wt due to fear of eating.
- Duodenal = Initial improvement w/eating (no wt loss seen)
Diagnosis
- Endoscopy
- Check CLO for HPylori
- Biopsy to excl. malignancy
Management
- Stop NSAID
- Treat Hpylori
- PPI
Complications
- Bleeding - gastroduodenal artery, haematamesis with hypotension treat with endoscopic intervention.
- Perforation of Peptic Ulcer - seen on X ray w/free air under diaphragm, present with acute abdo pain +/- Syncope
Mucosa secretes bicarbonate into this mucus coating to neutralise the stomach acid.
Factors that disrupt the mucus barrier or increase stomach acid risk mucosal ulcerations
RF: NSAIDs, HPylori, Stress, Alcohol, Smoking, Caffeiene, SSRIs
Small Bowel Obstruction
- Adhesions from prev. surgery common cause.
- Hernias another cause
Features
- Billous (green) vomitting
- Central abdo pain
- constipation with no flatulence
- Abdo distension
- tinkling bowel soundfs
Ix
- X ray - first line, Distended smll bowel loops with fluid level
- CT - definitive diagnosis
Management
- NBM
- IV fluids
- NG tube with free drainage
Some pts settle with conservative management but otherwise require surgery
Large Bowel Obstruction
- Main cause is tumour, othersL volvulus, diverticular disease
Features
- Abdo pain & distension
- N&V
- Peritonism
- No Flatus or stool
Ix
- Xray: free intra-peritoneal gas = perforation
- CT definitive
Management
- NBM
- IV fluids
- NG with free drainage
- Surgery if perforation suspected
- 75% require surgery
- IV Abx given if surgery
Stents may be inserted into the bowel (during a colonoscopy) in patients with obstruction due to a tumour. Stents hold the tumour out of the way, creating space for the bowel contents to move through.
