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Phase 2 Quick > GI > Flashcards

GI Flashcards

1
Q

Causes GORD

A

Obesity
Hiatus hernia (bc LOS sphincter can’t close properly)
LOS HTN
Loss of oesophageal peristaltic function
↑ Abdo pressure = pregnancy
Overeating
Systemic sclerosis

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2
Q

Signs / Symptoms GORD

A

Heartburn - burning chest pain
Odynophagia
Hoarse throat
Wheezing
Acidic taste
Waterbrash
Regurgitation

Nocturnal asthma
Chronic cough
Laryngitis
Sinusitis

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3
Q

DDx GORD

A

Coronary artery disease
Biliary colic
Peptic ulcer
Malignancy

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4
Q

Ix GORD

A

Usually just diagnosed w clinical findings (as long as there’s no red flags)

Oesophago-Gastro-Duodenoscopy - can show oesophagitis & hiatus hernia

24 hour intraluminal pH monitoring

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5
Q

Tx GORD

A

Lifestyle changes - stop smoking, lose weight, small regular meals

Antacids e.g. Gaviscon

PPI e.g. omeprazole, lansoprazole

H2 receptor antagonists e.g. cimetidine, rainitide

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6
Q

How do H2 receptor antagonists work to treat GORD?

A

Blocks histamine receptors on parietal cells
∴ ↓acid release

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7
Q

How does PPI work to treat GORD?

A

Inhibits gastric hydrogen release
∴ prevents production of gastric acid

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8
Q

Complications GORD

A

Barret’s Oesophagus
Peptic stricture

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9
Q

What is Barret’s Oesophagus?

A

When oesophageal epitheliu undergoes metaplasia
SQUAMOUS -> COLUMNAR w/ goblet cells

Risk of progression to oesophageal cancer
(premalignant for adenocariconoma)

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10
Q

What is a Peptic stricture?

A

Inflammation of oesophagus (bc gastric acid exposure)
∴ narrowing + stricture of oesophagus

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11
Q

What is a peptic ulcer?

A

Break in the epithelial cells which penetrate down to muscularis mucosa
Happens in stomach OR duodenum

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12
Q

What people are peptic ulcers more common in?

A

Elderly
Developing countries

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13
Q

State some easy ways to differentiate between symptoms of a peptic ulcer in the STOMACH and one in the DUODENUM

A

Duodenal ulcer - relieved by eating, MC

Gastric ulcer - worsened by eating, assoc w/ NSAIDs/aspril

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14
Q

Causes Peptic ulcers

A

H. Pylori - MC

NSAIDs
Mucosal Ischaemia
↑ Acid
Bile reflux
Alcohol

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15
Q

Describe the mechanism for H.Pylori causing Peptic ulcers

A

H.Pylori lives in gastric mucus

Secretes urease, catalyst for :
Urea -> CO2 + ammonia

Then, Ammonia + H+ -> ammonium

Ammonium (+ proteases, phospholipidases etc) damages gastric epithelium

∴ inflam response
∴ ↓ mucosal defence
∴ Mucosal damage
–
ALSO, causes ↑acid secretion :

Gastrin release (from G cells)
Histamine release
↑Parietal cell mass
↓Somatostatin

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16
Q

Describe the mechanism for NSAIDs causing Peptic ulcers

A

Prostaglandins stimulate mucus secretion & COX-1 is needed for prostaglandin stimulation

BUT NSAIDs inhibit COX-1
∴ mucus isn’t secreted
∴ ↓mucosal defence
∴ ↓mucosal damage

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17
Q

Describe the mechanism for mucosal ischaemia causing Peptic ulcers

A

Stomach cells not supplied w enough blood
∴ cells die off
∴ don’t produce mucin

Gastric acid attacks those cells & they die
∴ ulcer forms

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18
Q

Describe the mechanism for increased acid causing Peptic ulcers

A

↑↑ Acid overwhelms the mucosal defence and attacks mucosal cells
Cells die and ulcer forms !
Stress can also increase acid production

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19
Q

Signs / Symptoms Peptic ulcers

A

Sometimes asymptomatic

Burning epigastric pain!
Tender epigastrum
Bloating
N+V
Haematemesis/Melaena
Dyspepsia
Dysphagia
Flatulence
Anorexia
Heart burn (retrosternal)
–
Gastric - pain occurs when Px is hungry or eating. Usually occurs at night
Presents w weight loss

Duodenal - pain occurs several hours after meals, relieved by eating
Presents w weight gain

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20
Q

RED FLAGS FOR CANCER

A

UNEXPLAINED WEIGHT LOSS
ANAEMIA
EVIDENCE OF GI BLEEDING
DYSPHAGIA
UPPER ABDO MASS
PERSISTENT VOMITING

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21
Q

Ix Peptic ulcers

A

GS - Endoscopy w biopsy!

Stool antigen test & Urea breath test- for H.Pylori
stop PPI/Abx for at least 2/4 weeks before test

Autoimmune - low B12, parietal cell antibodies, IF antibodies

Blood test for IgG antibodies (can be pos for a year after tx)

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22
Q

Tx Peptic ulcers

A

Lifestyle changes - ↓Alcohol, ↓tobacco

Treat H.Pylori - CAP (clarithromycin, amoxicillin, PPI)!!
H2 antagonists - cimetidine

Surgery if comps

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23
Q

Comps Peptic ulcers

A

GASTRITIS

Duodenal ulcers can keep growing until reaches artery (gastroduodenal artery) and cause massive haemorrhage

Obstruction
Peritonitis - acid enter peritoneum
Acute pancreatitis - if ulcer reaches pancreas

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24
Q

What is Gastritis?

A

Inflam of stomach lining
Assoc w mucosal injury

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25
Q

Causes Gastritis

A

H.Pylori

Peptic ulcer - can develop into gastritis if happens regularly

Autoimmune gastritis
Viruses - CMV, HSV
Duodenogastric reflux
Crohn’s disease
Mucosal ischaemia
↑Acid
Aspirin and NSAIDs
Alcohol

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26
Q

How does autoimmune gastritis cause gastritis?

A

Autoimmune gastritis affects fundus and body of stomach
∴ Atrophic gastritis and ↓ parietal cells with IF def = pernicious anaemia

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27
Q

Signs / Symptoms Gastritis

A

Epigastric pain
N+V
Recurrent upset stomach
Indigestion
Loss of appetite
Abdo bloating
Haematemesis
Anaemia

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28
Q

DDx Gastritis

A

Peptic ulcer
GORD
Gastric lymphoma
Gastric carcinoma

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29
Q

Ix Gastritis

A

Upper GI endoscopy
Biopsy and histology

H.Pylori urea breath & stool antigen tests
Bloods - anaemia
Faecal occult blood tests

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30
Q

Tx Gastritis

A

CAP - clarithromycin, amoxicillin, PPI (omeprazole)

H2 antagonists - ranitidine, cimetidine

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31
Q

Prevention Gastritis

A

Give PPIs alongside NSAIDs
also prevents bleeding from acute stress ulcers and gastritis (seen in px esp burn patients)

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32
Q

Histology Coeliac disease

A

Villous atrophy
Crypt hyperplasia

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33
Q

When does Coeliac disease usually present?

A

In infancy OR 40s - 60s

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34
Q

Why is prevalence of coeliac disease increasing?

A

Changes in endoscopic techniques
Antibody screening
↑Awareness of spectrum of presentation of coeliac disease

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35
Q

Describe the Marsh Classification

A

0 normal
1 raised intra epithelial lymphocytes (IEL)
2 raised ILE + crypt hyperplasia
3a partial villous atrophy (PVA)
3b subtotal villous atrophy (SVA)
3c total villous atrophy (TVA)

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36
Q

Where is gluten found?

A

Wheat
Barley
Rye

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37
Q

Pathophysiology Coeliac disease

A

TYPE 4 HS REACTION

Gluten breaks down to a-gliadin, triggers immune response to produce Abs - anti-TTG and anti-EMA

These target epithelial cells of small intestine causing :
- Villous Atrophy
- Crypt hyperplasia
- Intra-epithelial lymphocytes

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38
Q

Antibodies in Coeliac Disease

A

Anti-TTG - Anti-Tissue Transglutaminase

Anti-EMA - Anti-Endomysial

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39
Q

RF Coeliac Disease

A

Other autoimmune diseases
IgA def
Breast-feeding
Age of gluten introduction into diet
Rotavirus infection in infancy ↑risk
H.Pylori

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40
Q

Signs / Symptoms Coeliac disease

A

CLASSICAL :
Diarrhoea
Steatorrhoea
Abdo pain
Abdo distention
Weight loss
Failure to thrive
Nutritional def
–
NON-CLASSICAL :
Dermatitis herpetiformis
IBS symptoms
Iron def anaemia
Osteoporosis
Chronic fatigue
Ataxia
Periph neuropathy
Hyposplenism
Amenorrhoea
Infertility

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41
Q

Ix Coeliac disease

A

SEROLOGY
1st Line - Anti-tissue transglutaminase (tTG)
2nd Line - Anti-endomysial antibody (EMA)
Anti-gliadin

GS!! Endoscopy w/ duodenal biopsy -
VILLOUS ATROPHY
Crypt Hyperplasia
Intra-epithelial lymphocytes

FBC - ↓Hb, ↓B12, ↓ferritin

Autoimmune condition screening - DMT1 etc

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42
Q

Tx Coeliac disease

A

Gluten free diet - strict, lifelong
No barley, wheat, rye

Dietician review - correct vit defs
DEXA scan - osteoporosis risk

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43
Q

Comps Coeliac disease

A

T-cell lymphoma
Osteoporosis
Anaemia
Infertility
Hyposplenism
Vit D def - steatorrhoea, night blindness, bruising etc

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44
Q

Types of IBD

A

Crohn’s
UC

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45
Q

Who does Crohn’s most likely affect?

A

F
20 - 40 years
Northern Europe, UK and North American countries

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46
Q

RF Crohn’s

A

FHx - Mutation on NOD2 gene (chromosome 16)
Smoking
Female
Chronic stress
NSAIDs

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47
Q

Crohn’s : CHRISTMAS

A

Cobblestones
High temp
Reduced lumen
Intestinal fistulae
Skip lesions
Transmural
Malabsorption
Abdo pain
Submucosal fibrosis

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48
Q

Signs / Symptom Crohn’s

A

RLQ abdo pain (ileum)
Diarrhoea
N+V
Fatigue
Fever
Tenderness
Haematochezia, Meleana
Mouth ulcers

Extra-Intestinal features :
Erythema nodosum
Anal fissures/strictures
Episcleritis
Clubbing, skin, joint & eye problems

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49
Q

Comps Crohn’s

A

Small bowel obstruction
Toxic dilation
Abscess formation
Fistulae
Malnutrition
Perforation
Anal - skin tags, fissure, fistula
Neoplasia - colorectal cancer

Amyloidosis - rare

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50
Q

DDx Crohn’s

A

Chronic diarrhoea

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51
Q

Ix Crohn’s

A

GS!! Colonoscopy & biopsy

Barium enema

Should always rule out other causes of diarrhoea (Salmonella spp., Giardia intestinalis, rotavirus) - Stool sample

FBC - ↑ESR/CRP, ↓Hb, neg p-ANCA

Malabsorption - ferritin, B12, folate

Faecal calprotein aka FIT test - indicates IBD, not spec

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52
Q

Tx Crohn’s

A

1 - Oral corticosteroids - budesonide, prednisolone
If severe, IV hydrocortisone (severe flare ups)

2a - + 5-ASA (azathioprine)
b. Methotrexate

3 - Anti-TNF antibodies - infliximab

4 - Surgery

–
DISEASE IS NOT CURATIVE
–
To maintain remission! Azathioprine or Methotrexate

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53
Q

What part of the body does Crohn’s affect?

A

Affects any part of gut from mouth to anus - ileum and colon esp
Originates in mucosa and works through layers of the bowel

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54
Q

Describe macroscopic features of Crohn’s

A

Skip lesions
Cobblestone appearance (due to ulcers and fissures in mucosa)
Thickened & narrow

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55
Q

Describe microscopic features of Crohn’s

A

Transmural - affects all layers of the bowel
Non-caseating granulomas
Goblet cells

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56
Q

What are non-caseating granulomas?

A

Aggregations of epithelioid histiocytes

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57
Q

RF UC

A

FHx
NSAIDs - assoc/ w onset and flares of IBD
Chronic stress, depression triggers flares

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58
Q

What rogue thing can relieve UC?

A

Smoking

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59
Q

Describe some macroscopic features of UC

A

Continuous inflam (no skip lesions)
Ulcers
Pseudo-polyps

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60
Q

Describe some microscopic features of UC

A

Mucosal inflam
No granulomata
Depleted goblets cells
Increase crypt abscesses

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61
Q

What area of the body does UC affect?

A

Remains in mucosa (doesn’t go through full wall of bowel)
Only affects colon
NEVER goes past the ileocaecal valve

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62
Q

Who might UC be found in?

A

Affects males and females equally
Presents between 15 - 30
Northern Europe, UK and N. America

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63
Q

Signs / Symptoms UC

A

LLQ abdo pain
Fever
Diarrhoea w blood and mucus
Cramps
Rectal tenesmus - incontinence, urgency, bleeding
Tender, distended abdo
Clubbing
Erythema nodosum

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64
Q

UC : ULCERATION

A

Ulcers
Large intestine
Carcinoma - risk of
Extra-intestinal manifestations
Remnants of older ulcers - psuedo polyps
Abscesses in crypts
Toxic megacolon - risk of
Inflamed, red, granular mucosa
Originates at rectum
Neutrophil invasion
Stool is bloody and has mucous

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65
Q

Ix UC

A

GS!! Colonoscopy & biopsy (crypt abscesses, goblet cell depletion)
also, allows to assess disease extent

Barium enema

Bloods - FBC (↑ESR,↑CRP, ↓Hb)
p-ANCA might be pos (deff neg in Crohn’s so can differentiate)

Faecal calprotein

Stool sample - to rule out other causes of diarrhoea (Salmonella etc)

CT/MRI

Abdo XR - useful if UC is too severe for colonoscopy, can be used to exclude colonic dilation

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66
Q

Extra-Intestinal Manifestations of UC

A

A PIE SAC

Ankylosing Spondylitis

Pyoderma Gangrenosum
Iritis - ant. uvieitis
Erythema nodosum

Sclerosing cholangitis
Apthous ulcers / Amyloidosis
Clubbing

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67
Q

What should you avoid with Crohn’s?

A

NSAIDs

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68
Q

Tx UC

A

Aminosalicylate (5-ASA)
e.g. Sulfasalazine, Mesalazine

MILD
1. 5-ASA
2. + steroid (prednisolone)

MOD/SEVERE
1. Fluid/resus if necessary
2. IV steroid (hydrocortisone)
3. + TNF-i (infliximab)

GS!! COLECTOMY

To maintain remission - azathioprine

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69
Q

Where is 5-ASA absorbed?

A

Small intestine

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70
Q

Comps UC

A

Liver - fatty change, chronic pericholangitis, sclerosing cholangitis

Colon - blood loss, toxic dilation, colorectal cancer

Skin - erythema nodosum, pyoderma gangrenosum

Joints - Ankylosing spondylitis, arthritis

Eyes - Iritis, uveitis, episcleritis

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71
Q

Define diarrhoea

A

Abnormal passage of loose or liquid stool more than 3 times daily

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72
Q

Define acute diarrhoea

A

Lasts less than 2 weeks

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73
Q

Define chronic diarrhoea

A

Lasts more than 2 weeks

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74
Q

Viral causes of diarrhoea

A

Most cases are caused by viruses

e.g.
Rotavirus - children
Norovirus - adults

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75
Q

Bacterial causes of diarrhoea

A

Campylobacter
Shigella
Salmonella
C.perfringens
S.aureus
B.cereus
E.coli
C.diff
Parasites (e.g. giardia, crypto)

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76
Q

Antibiotic causes of Diarrhoea??

A

Some abx can give rise to C.Diff diarrhoea

RULE OF Cs
Clindamycin
Ciprofloxacin
Co-amoxiclav
Cephalosporins (esp 2nd + 3rd gen)

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77
Q

Infective causes of diarrhoea

A

Intraluminal infection
Systemic infections e.g. sepsis, malaria

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78
Q

Non-infective causes of diarrhoea

A

Cancer
Chemical e∴g poisoning, sweeteners, s/e
IBS/Malabsorption
Endo e.g. T4
Radiation

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79
Q

Mechanism for watery diarrhoea

A

Non-Inflam
Enterotoxin or superficial adherence/invasion

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80
Q

Mechanism for bloody, mucoid diarrhoea

A

Inflam!

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81
Q

Location of watery diarrhoea

A

Proximal small bowel

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82
Q

Location of bloody, mucoid diarrhoea

A

Colon

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83
Q

Bacterial causes of watery diarrhoea

A

Vibrio cholerae
E.Coli
Clostridium perfringes
Bacillus cereus
S. Aureus

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84
Q

Bacterial causes for bloody, mucoid diarrhoea

A

Shigella
E.Coli
Salmonella enteridis
C.parahaemolyticus
C.diff
C.jejuni

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85
Q

Viral causes of watery diarrhoea

A

Rotavirus
Norovirus

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86
Q

Viral causes of bloody, mucoid diarrhoea

A

N/A

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87
Q

Parasitic causes of watery diarrheoa

A

Giardia
Cryptosporidium

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88
Q

Parasitic causes of bloody, mucoid diarrhoea

A

Entamoeba histolytica

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89
Q

History Diarrhoea

A

HISTORY IS KEY!

> Onset/duration
Acute - viral/bacterial
Chronic - parasites and non-infectious

> FHx

> Stool characteristics
Floating - fat content, malabsorption/coeliac
Blood/mucus - inflam, cancer
Watery - small bowel infection

> Food/drink
Dodgy takeaway - food poisoning
Meat/BBQs - campylobacter
Poultry - salmonella

> Travel
No cholera in UK
Foreign travel?
V common

> Immunocomp?
HIV, chemo, transplant etc

> Unwell contacts

> Fresh water/swimming - giardia, crypto

> Animals
Reptiles - salmonella
Puppies - campylobacter

> Medications? Abx??

> Neuro signs?
Clostridium botunilum - ascending weakness
C.jejnuni - guillain-barre

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90
Q

Ix Diarrhoea

A

HISTORY

Stool tests - culture, faecal calprotein, occult blood, microscopy, cysts, parasites etc

Bloods - FBC, inflam markers (CRP etc), blood culture

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91
Q

What is the 1st and 2nd leading causes of death in children globally?

A

1st - Pneumonia
2md - Infective diarrhoea

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92
Q

Where does infective diarrhoea have the highest prevalence?

A

S.Asia
S.Africa

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93
Q

DDx Infective diarrhoea

A

Appendicitis
IBD
UTI
Coeliac disease
Volvulus

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94
Q

RF Infective diarrhoea

A

Foreign travel
PPI or H2 antagonist use
Crowded use
Poor hygiene

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95
Q

Causes infective diarrhoea

A

*Enterotoxigenic E.Coli - MC
Campylobacter
Shigella
Viral
Non-typhoidal salmonella
V.parahaemolyticus - shellfish!

Cholera - vibrio cholerae

Parasites - protozoal (crypto, giardia, entamoeba)

Worms - schistosomiasis, strongyloides

C.DIff

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96
Q

Ix Infective diarrhoea

A

3 or more unformed stools per day + one of the following :

Abdo pain
Cramps
N / V
Dysentry

–
Blood - suggests bacteria
Stool sample
If chronic, sigmoidoscopy

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97
Q

What bacteria cause bloody stools

A

E.Coli and shigella ALL cause bloody stools

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98
Q

Tx Infective diarrhoea

A

Rehydration
Fluids + electrolytes - monitoring and replacement

ABx - metronidazole or oral vancomycin

Barrier nursing - side room, gloves, apron

Anti-emetics - treat vomiting w/ metoclopramide

Anti-motility agents - BUT NEVER IN INFLAM DIARRHOEA

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99
Q

Diarrhoea red flags?

A

Dehydration
Electrolyte imbalance
Renal failure
Immunocompromised
Severe abdo pain

100
Q

Quick! Right side abdo pain
First thoughts?

A

Appendicitis
unless already removed

101
Q

Where is the appendix located?

A

At McBurney’s point
2/3 from umbilicus to anterior superior iliac spine (ASIS)

102
Q

When does appendicitis occur?

A

Any age
but highest incidence is at 10-20 years

103
Q

Causes appendicitis

A

OBSTRUCTION

Faecolith - faeces stones
Filarial worms
Undigested seeds
Lymphoid hyperplasia
Bacteria - Campylobacter jejuni, Yersinia, salmonella, bacillus cereus

104
Q

Pathophysiology Appendicitis

A

Appendix is blocked
∴ ↑gut flora
∴ immune response summoned
∴ ↑ WBC

∴ appendix swells and presses against nerves
= ouch

105
Q

Signs / Symptoms Appendicitis

A

Acute pain in R iliac fossa/umbilicus
Might originate in umbilicus and then migrate to RIF

N+V
Fever
Guarding
Rebound/percussion tenderness w palpation
Pyrexia
Rovsing’s sign
Psoas sign / Cope sign

106
Q

What is Rovsing’s sign?

A

More pain in RIF when LIF is pressed

107
Q

What is Cope sign?

A

Pain on flexion and internal rotation of R hip
Happens if appendix is close to obturator internus

108
Q

What is Psoas sign?

A

Pain on extending hip
happens if retrocaecal appendix

109
Q

DDx Appendicitis

A

Gynae :
Ectopic pregnancy!
Ovarian torsion
Ruptured ovarian cyst

GI :
Crohn’s
Food poisoning
Mesenteric adenitis
Diverticulitis/Cholecystitis/Cystitis

GU :
Kidney stones
UTI
Testicular torsion

110
Q

Ix Appendicitis

A

Bloods - maybe ↑neutrophil and ↑CRP

Abdo US - but not always helpful to see appendix

GS!! CT w contrast

Urinalysis - exclude UTI
Pregnancy test

111
Q

UC Extra-intestinal signs

A

A PIE SAC

Ankylosing spondylitis

Pyoderma gangrenosum
Iritis
Erythema nodosum

Sclerosing cholangitis
Apthous ulcers/Amyloidosis
Clubbing

112
Q

Comps Appendicitis

A

Peritonitis - if ruptures

113
Q

Tx Appendicitis

A

Appendicectomy - usually laparoscopic
can be open surgery if required

114
Q

Causes of Peritonitis

A

AEIOU

Appendicitis
Ectopic pregnancy
Infection with TB (bacterial MC)
Obstruction
Ulcer

115
Q

Common causes of abdo pain

A

Gastritis - epigastric pain
Cholecystitis - R hypochondrium, mid-clav line
Pancreatitis - midway between epigastric and umbilicus
Appendicitis - R iliac fossa
Diverticulitis - L iliac fossa

116
Q

What is diverticulosis?

A

When a diverticula is present

117
Q

What is diverticular disease?

A

When diverticula are symptomatic

118
Q

What is diverticulitis?

A

When diverticula are inflamed

119
Q

What’s a true diverticulum?

A

Involves all layers of intestinal wall

120
Q

What’s a false diverticulum?

A

Involves only mucosa and submucosa

121
Q

RF Diverticulosis

A

LOW FIBRE DIET (+ high meat)
Obesity
CONSTIPATION
Smoking
NSAIDs
> 50 years - occur in 50% of people over 50

122
Q

Pathophysiology Diverticulosis

A

Fibre helps gut motility
∴ if ↓ fibre, colon must push harder to move things along
∴ ↑ pressure

∴ Pouches of mucosa extrude beyond muscular wall near blood vessels

∴ diverticula form at gaps of colon wall where blood penetrate

123
Q

Signs / Symptoms Diverticulosis

A

Asymptomatic !!

Maybe erratic bowel habit
Or if severe, intermittent LIF pain + constipation

124
Q

Ix Diverticulosis

A

Usually detected incidentally w/ colonoscopy or barium enema

125
Q

Tx Diverticulosis

A

If symptomatic, recommend high fibre diet and smooth muscle relaxants e.g. mebeverine

126
Q

Where is diverticulitis normally found?

A

Sigmoid colon

127
Q

Pathophysiology Diverticulitis

A

Occurs when faeces obstructs neck of diverticulum
∴ bacteria multiply
∴ inflammation!!

128
Q

Signs / Symptoms Diverticulitis

A

Same as appendicitis but LEFT ILIAC FOSSA

Severe pain in LIF
Fever
N+V
Rebound tenderness w palpation
ETC

129
Q

Ix Diverticulitis

A

FBC - ↑WBC, ↑ESR, ↑CRP

CT w contrast - will show colon wall thickening + abscesses

Bowel sounds diminished? (colon not working properly)

Colonoscopy - use for acute bleeds
but not if bleeding profusely bc can perforate bowel more

Could also do abdo XR and barium enema if you wanted

130
Q

Tx Diverticulitis

A

If mild - fluids, bowel rest, ABx e.g. ciprofloxacin

If seems severe/systemic - treat w/ IV fluids, IV Abx

RARELY but sometimes surgical resection

131
Q

Symptoms of diverticular disease
AND Diverticulitis

A

BBL

Bowel habits changed
Bloating/flatulence
Left lower quadrant pain

If diverticulitis :
All of above
+ FEVER
+ Blood in stool

132
Q

Comps Diverticular disease

A

Infection -> abscess
Bowel perforation
Peritonitis
Haemorrhage
Obstruction
Fistulae (into adjacent organs)

133
Q

What should you not do during an acute attack of diverticulitis?

A

DO NOT PERFORM COLONOSCOPY OR SIGMOIDOSCOPY

134
Q

What can IBS symptoms be exacerbated by?

A

Stress
Food
Gastroenteritis
Menstruation

135
Q

Age of onset IBS

A

< 40 years

136
Q

3 types of IBS

A

IBS-C - w constipation
IBS-D - w diarrhoea
IBS-M - w both

137
Q

What is Irritable Bowel Syndrome?

A

Recurrent abdo pain with NO inflammation

138
Q

Signs / Symptoms IBS

A

Abdo pain relieved by defecating or passing of wind
Bloating
Alternating bowel habits
Constipation
Diarrhoea
Mucus in stools
Change in stool freq/consistency
Urgency
Worsening symptoms after food

139
Q

Ix IBS

A

FBC - for anaemia
ESR, CRP - for inflammation

Coeliac serology for EMA and ttG - if +, then probs coeliac disease, not IBS

Faecal calprotein - IBD

Colonoscopy - IBD, colorectal cancer

140
Q

Tx IBS

A

Lifestyle - fluids
Avoid caffeine & alcohol & fizzy drinks
Low FODMAP diet !!
Educate patient & reassure

Treat symptoms :
Pain/bloating - antispasmodic e.g. Buscopan
Constipation - laxative e.g. Senna, avoid lactulose
Diarrhoea - antimotility e.g. Loperamide

If none of the above work, Amitriptyline

141
Q

What are FODMAPs?

A

Fermentable - carbs brown down in colon
Oligosaccharides - wheat, rye, onione, garlic, legumes, lentils, artichokes
Disaccharides - lactose! Milk, icecream etc
Monosaccharides - Fructose - apples, watermelon, mango, pear, asparagus
And
Polyols - sorbitol, mannitol, gum, cauliflower, fruits, sweets

142
Q

What is the Roman IV criteria?
What does it help diagnose?

A

Recurrent abdo pain at least 1 day/week for the past 3 months
& symptoms began at least 6 months ago plus AT LEAST 2 of :
relieved by defecation
change in bowel appearance
change in bowel freq

IBS

143
Q

Oesophageal Tumour Staging

A

T1 - invading lamina propria/submucosa
T2 - invading Muscularis propria
T3 - invading adventitia
T4 - invasion of adjacent structures

N0 - no nodal spread
N1 - regional node metastases

M0 - no distant spread
M1 - distant metastases

144
Q

2 Types of Oesophageal Cancer

A

Squamous cell carcinomas
Adenocarcinomas

145
Q

Where is Oesophageal squamous cancer commonly found?
Geographically

A

Ethiopia
China
South and East Africa

146
Q

Where is Oesophageal adenocarcinoma commonly found?
Geographically

A

Western countries

147
Q

Causes Oesophageal squamous cancer

A

↑↑Alcohol
Smoking

Achalasia
Obesity
Smoking
↓Fruit and Veg

148
Q

Cause Oesophageal adenocarcinoma

A

GORD - Barret’s oesophagus!!

Smoking
Obesity

149
Q

Where in the body is Oesophageal squamous cancer found?

A

Upper 2/3rds of the oesophagus
Middle third MC

150
Q

Where in the body is Oesophageal Adenocarcinoma found?

A

Lower 1/3rd of oesophagus

151
Q

Pathophysiology of Oesophageal Cancer

A

Oesophagus - squamous epithelium
Stomach - columnar glandular epithelium

Oesophageal epithelium undergoes metaplasia to stomach epithelium!

152
Q

Signs / Symptoms Squamous cell Oesophageal Cancer

A

Normally none! Bc only detectable when advanced

Progressive dysphagia i.e. solids followed by liquids

Weight loss
Anorexia
Hoarse voice - pressing on recurrent laryngeal nerve
Odynophagia
ALARMS !! Cancer red flags

153
Q

When would you get a 2 week endoscopy referral?

A

People with :

Dysphagia
OR
Age ≥ 55 years w/ weight loss AND at least 1 of :
Upper abdo pain
Reflex
Dyspepsia

154
Q

If dysphagia to solids AND liquids at the same time, what does this indicate?

A

Benign disease

155
Q

Ix Oesophageal cancer

A

Oesophagoscopy w/ biopsy !!!

Barium swallow - to see strictures

CT/MRI/PET for staging

156
Q

Tx Oesophageal cancer

A

Surgical resection
w/ adjuvant radio/chemo

Palliative care :(
5 year prognosis is 25%

157
Q

What considerations have to be taken when considering surgery for GI cancer?

A

Is patient medically fit? Age? Co-morbs?
Severity of cancer?
Is it resectable?

158
Q

Why is prognosis for Oesophageal cancer relatively poor?

A

Bc symptoms arise so late into disease

159
Q

MC benign oesophageal tumour
Describe it

A

Leiomyomas
Smooth muscle tumours, arise from oesophageal wall
Intact, well-encapsulated within overlying mucosa
Slow-growing

160
Q

Signs / Symptoms Benign Oesophageal cancer

A

Asymptomatic - usually found incidentally on barium swallow

Can present w dysphagia, retrosternal pain, food regurg + recurrent chest infections

161
Q

Where does Gastric cancer commonly affect?

A

Eastern Europe
Asia

162
Q

Causes Gastric Cancer

A

Unknown
Some link w smoking

163
Q

RF Gastric cancer

A

Smoking
H. Pylori - bc ↑risk of peptic ulcer
Male

164
Q

Signs / Symptoms Gastric cancer

A

Epigastric pain - constant and severe!!
Virchow’s node! ( L supraclavicular)

N+V
Anorexia
Weight loss
Dysphagia - if tumour in fundus
Anaemia - occult blood loss
Haematemesis/Melaena
Liver metastasis = jaundice
CANCER RED FLAGS

165
Q

Ix Gastric Cancer

A

Gastroscopy w/ biopsy
Neg biopsy doesn’t mean deff no cancer - need to do 8-10 biopsies to make sure !

Endoscopic ultrasound
CT/MRI/PET

166
Q

Types of Gastric Cancer
Brief description

A

Type 1 - Intestinal
Well-formed, differentiated cells
Metaplasia in surrounding mucosa
Tumours = polypoid OR ulcerating lesions w/ heaped, rolled edges
Found often in patients w/ atrophic gastritis

Type 2 - Diffuse
Poorly cohesive, undifferentiated cells
Often will infiltrate gastric wall
Worse prognosis

167
Q

Which type of gastric cancer is most common?

A

Intestinal (80%)

168
Q

Where is intestinal gastric cancer found in the body?

A

Antrum + lesser curvature

169
Q

Where is diffuse gastric cancer found in the body?

A

Anywhere in the stomach
Esp cardia

170
Q

RF Intestinal Gastric cancer

A

Male
Older age
H. Pylori
Chronic or Atrophic Gastritis

171
Q

RF Diffuse Gastric Cancer

A

Female
< 50 years
Blood type A
Genetics
H. Pylori infection

172
Q

Histology Intestinal Gastric cancer

A

Well-differentiated
Tubular

173
Q

Histology Diffuse Gastric Cancer

A

Poorly differentiated
Signet ring cells

174
Q

Pathophysiology Intestinal Gastric cancer

A

Chronic gastritis -> Atrophic gastritis
∴ intestinal metaplasia and dysplasia

175
Q

Pathophysiology of Diffuse Gastric cancer

A

Development of linitis plastica (leather bottler stomach)
?

176
Q

Tx Gastric Cancer

A

Nutritional support!

Surgical resection - can be subtotal or total gastrectomy
+ adjuvant radio/chemo

ECF chemo - Epirubicin + cisplatin + 5-fluororacil

177
Q

Prognosis Gastric cancer

A

STAGE 1 - 70% 5 year survival
STAGE 4 - 5.5% 5 year survival

178
Q

Diff between peptic ulcler pain and gastric cancer pain

A

Peptic ulcer pain can be relieved by food and antacids
But gastric cancer pain is constant and vv severe

179
Q

What is the staging for Colorectal cancer?
Describe it

A

DUKE STAGING

A - 95% 5 year survival
Limited to mucosa

B - 75% 5 year survival
Through bowel lining and into submucosa
Not lymph nodes

C - 35% 5 year survival
Involvement of lymph nodes

D - 25% 5 year survival
Metastatic! Distant organs affected

180
Q

What age is the majority of presentation of colorectal cancer?

A

> 60 years old

181
Q

RF Colorectal cancer

A

Age
FHx
IBD
Obesity
DM
Smoking
Alcohol

Genetics - FAP & HNPCC

182
Q

Causes Colorectal cancer

A

Mostly due to random mutations but some are known e.g.

Familial adenomatous polyposis (FAP)
Mutation in APC (tumour suppressor gene)
Polyps formation

Hereditary non-polyposis colorectal cancer (HNPCC) - Lynch Syndrome
AUTOSOMAL DOMINANT
Normally 2 DNA protein repair genes
But some people only have 1 and ∴ susceptible

183
Q

Where in the body is colorectal cancer most common?

A

Sigmoid colon
Rectum

184
Q

Signs / Symptoms Colorectal cancer

A

Depends on region affected!

Ascending colon carcinoma
Usually ASx for ages until iron def anaemia bc of bleeding
Weight loss
Abdo pain
May present w/ mass

Descending colon and sigmoid carcinoma
Change in bowel habit w blood +/- mucus in stool
Diarrhoea
Alternative constipation and diarrhoea
Thin/altered stool

Rectal carcinoma
Rectal bleeding and mucus
If cancer grows, thinner stools and tenesmus
–
EMERGENCY! - OBSTRUCTION
Absolute constipation
Colicky abdo pain
Abdo distention
Vomiting (faeculent)

185
Q

Ix Colorectal cancer

A

Colonoscopy/Sigmoidoscopy + biopsy! - GS!!!!!!!

CT colonography - if unfit for colonoscopy
CT TAP (thorax, abdomen and pelvis) - for staging

Carcinoembryonic antigen - CEA

Digital rectal exam - 38% of colorectal cancers can be detected by DRE !

Double contrast barium enema

FBC

186
Q

When does bowel cancer screening happen?
What does it include?

A

60 - 74 years
Every 2 years

Faecal immunochemical test (FIT)

187
Q

What is Duke’s Classification for?

A

Colorectal cancer
AND THERE IS ALSO ONE FOR INFECTIVE ENDOCARDITIS

188
Q

Tx Colorectal cancer

A

Surgery -
Endoscopy stenting
Radio/Chemo

189
Q

Which GI cancer is very rare?

A

Small intestine
usually adenocarcinoma

Usually SI is resistant to neoplasms

190
Q

Tx H. Pylori

A

Triple therapy - CAP !! / CMP
2x a day for 7 days! (NICE guidlines)

Clarithromycin 500mg + Amoxicillin 1g + PPI

If penicillin allergy, Metronidazole 400 mg instead of amoxicillin

191
Q

Ix H. Pylori

A

Urea breath test
Stool antigen test

Before testing, stop PPI for at least 2 weeks and Abx for 4 weeks
(???? is this rlly true? that’s so long to stop meds !)

192
Q

Define an intestinal obstruction

A

Arrest or blockage of onward propulsion of intestinal contents

193
Q

Causes of Small Bowel Obstruction

A

MECHANICAL :
Adhesions!! (75%)
Usually 2º to abdo surgery
↑Incidence w/ pelvic, gynae, colorectal surgery

Hernias (10%)

Rarer : Malignancy, Crohn’s

194
Q

2 Types of intestinal obstruction

A

Mechanical - can be partial or complete
Functional - ‘paralytic ileus’, disruption of peristalsis

195
Q

Describe the classifications of bowel obstruction

A

> Site ?
Large bowel, small bowel etc

> Extent of luminal obstruction?
Partial, complete

> Mechanism?
Mechanical, function

> Pathology?
Simple, closed loop, strangulation, intussusception

196
Q

Ix SBO

A
  1. Abdo XR
    Central gas shadow, crosses lumen, NO GAS IN LARGE BOWEL
    Dilation of small bowel > 3cm, coiled-spring appearance

GS : ABDO & PELVIS CT W/ CONTRAST

197
Q

Signs / Symptoms SBO

A

Colicky abdo pain - starts and stops abruptly then becomes diffuse
Higher than LBO

Abdo distension (less than LBO)

Vomiting following pain, then constipation
‘Tinkling’ bowel sounds

N+V
Anorexia
Increased bowel sounds
Tympanic percussion
Tenderness

198
Q

What would you hear on auscultation if there is a mechanical bowel obstruction?

A

High-pitched tinkling sound

199
Q

What would you hear on auscultation if there is a functional bowel obstruction?

A

Absence of normal bowel sounds

200
Q

Why does LBO have a greater degree of distension?

A

Bc the more distal the obstruction, the greater the distension

201
Q

Tx Small Bowel Obstruction

A

SAME AS LBO !!!

Stable - A-E assessment
‘Drip and suck’
Insert IV cannula, resus w/ IV fluids!!
NBM
Nasogastric tube to decompress stomach
Analgesia, anti-emetics, Abx

Unstable - Surgery
Treat according to cause

202
Q

Comps SBO

A

Infection - peritonitis
Tissue death - blood supply can be cut off to intestine

203
Q

Causes Large Bowel Obstruction

A

Malignancy! (90%)
Sigmoid volvulus (5%)

Diverticulitis
Intussusception - more common w children

204
Q

Why does LBO present slower and later than in SBO?

A

Bc Large Bowel has larger lumen
+ circular and longitudinal muscles
∴ ability of large bowel to distend = much greater

205
Q

Signs / Symptoms LBO

A

CONTINUOUS abdo pain
Severe abdo distension

Constipation first, THEN vomiting
(initially bilious then faecal)

Absent bowel sounds

Palpable mass ? - hernia, distended bowel loop, caecum
Fullness/bloating

206
Q

Ix LBO

A
  1. Abdo XR
    dilation of large bowel > 6cm
    dilation of caecum > 9cm
    Sigmoid volvulus - coffee bean appearance!

DRE - empty rectum, hard stools, blood

GS!! ABDO & PELVIS CT W CONTRAST

207
Q

Tx LBO

A

SAME AS SBO !!

Stable - A-E assessment
‘Drip and suck’
Insert IV cannula, resus w/ IV fluids!!
NBM
Nasogastric tube to decompress stomach
Analgesia, anti-emetics, Abx

Unstable - Surgery
Treat according to cause

208
Q

What is Pseudo-Obstruction also known as?

A

Ogilvie syndrome

209
Q

What is Pseudo-Obstruction?

A

Colonic dilation in the absence of mechanical obstruction

210
Q

Ix Pseudo-Obstrction

A
  1. Abdo XR
    Megacolon dilation > 10cm

GS!! - ABDO & PELVIC CT W CONTRAST
no transition zone!

211
Q

Causes Pseudo-Obstruction

A

Post-op
Medications - opioid, CCBs, antideps
Neurological - MS, Parkinson’s, Hirschsprung’s
Electrolyte imbalance
Recent trauma/surgery

212
Q

Tx Pseudo-Obstruction

A

‘Drip & suck’ management
IV neostigmine
Surgical decompression if unstable

213
Q

Pathophysiology Pseudo-Obstruction

A

Parasympathetic nerve dysfunction
∴ absent smooth muscle

214
Q

Comps Pseudo-Obstruction

A

Bowel ischaemia
Perforation

215
Q

What is Meckel’s Diverticulum?

A

True diverticulum connected to vitelline duct

216
Q

Diff between True and False diverticulum?

A

True = ALL Layers, includes muscle
False = does not include muscle

217
Q

What age is Meckel’s Diverticulum common?

A

0-2 years

218
Q

Signs / Symptoms Meckel’s Diverticulum

A

Usually ASx !!!

If does present :
In children - Painless haemotochezia
Intussueption
In adults - Bowel obstruction, unexplained GI bleeding

219
Q

Ix Meckel’s

A

Meckel’s Scan

220
Q

DDx Meckel’s

A

Appendicitis - apparently clinically indistinguishable?? but doesnt present w pain?? so i dont get it

221
Q

Tx Meckel’s

A

Usually laparoscopic surgery - removal of diverticulum

222
Q

What is Meckel’s also known as?

A

Pharyngeal pouch

223
Q

Difference microscopically between Coeliac disease and Tropical Sprue

A

GS for both = Jejunal tissue biopsy

Tropical Sprue = INCOMPLETE villous atrophy
Coeliac = COMPLETE villous atrophy

224
Q

What is Tropical Sprue?

A

Chronic inflam of the bowel, acquired from the tropics

225
Q

What “tropics” is Tropical Sprue acquired from?

A

India
South East Asia
Caribbean

226
Q

When should you suspect Tropical Sprue?

A

Patient is from tropical country
+ has chronic GI/Malabsorptive Symptoms

227
Q

Signs / Symptoms Tropical Sprue

A

Diarrhoea
Steatorrhoea
Weight loss
Abdo pain
Fatigue
Dehydration
Vit/Iron anaemia

228
Q

Tx Tropical Sprue

A

Drink treated water
Tetracycline for 6 months

229
Q

RF Acute Mesenteric Ischaemia

A

AF !!!!!!!!
Cardio risks

230
Q

Classic Triad of Chronic Mesenteric Ischaemia

A
  1. Central Colicky abdo pain after eating
  2. Weight loss
  3. Abdo bruit - bc turbulent blood flow
231
Q

Ix Chronic Mesenteric Ischaemia

A

CT W CONTRAST
or ANGIOGRAPHY

232
Q

Pathophysiology Chronic Mesenteric Ischaemia

A

Same as Angina in heart!

233
Q

Tx Chronic Mesenteric Ischaemia

A

Lifestyle
2º prevention
Surgery

234
Q

What is Acute Mesenteric Ischaemia?

A

MEDICAL EMERGENCY!!
Blockage of mesenteric arteries/veins

235
Q

Where is the most likely place to be affected in Acute Mesenteric Ischaemia?

A

Superior mesenteric Artery
∴ Small bowel

236
Q

Causes Acute Mesenteric Ischaemia

A

Thromboembolism
Vasospasm
Hernia - strangulated

237
Q

Signs / Symptoms Acute Mesenteric Ischaemia

A

CLASSIC TRIAD :::
1. Severe central colicky pain, worst after eating
2. Abdo bruit / Cardiac issues (AF!!)
3. Rapid hypovolaemia - shock!! (pallor, weak pulse etc)
–
N+V
Melaena/Haematochezia
Increasing Abdo distention

238
Q

Ix Acute Mesenteric Ischaemia

A

Bloods - ↑lactate (metabolic acidosis)

1st Line - CT w contrast / Angiography

GS!!! - COLONOSCOPY

239
Q

Tx Acute Mesenteric Ischaemia

A

ABx
+ Anticoags e.g. heparin
+ Surgery

240
Q

What is Mallory-Weiss Tear?

A

Linear mucosal tear at the oesophagogastric junction

241
Q

Cause Mallory-Weiss Tear

A

Sudden increase in intra-abdo pressure

e.g.
Vomiting
Coughing
Retching

242
Q

RF Mallory-Weiss Tear

A

Alcoholism
Forceful vomiting
Eating disorders
NSAID abuse
Male

243
Q

Signs / Symptoms Mallory-Weiss Tear

A

Vomiting
Abdo pain
Haematemesis
Retching
Postural hypotension
Dizziness
Melaena

244
Q

Ix Mallory-Weiss Tear

A

Endoscopy

245
Q

Tx Mallory-Weiss Tear

A

Most bleeds are minor, heal in 24 hours
Surgery if req

246
Q

Quick!
Difference between Mallory-Weiss tear and Oesophageal Varices?

A

Mallory-Weiss Tear is bc of ↑intra-abdo pressure e.g. retching, vomiting

Oesophageal Varices is bc ↑portal pressure e.g. CIRRHOSIS, schistosomiasis

Phase 2 Quick (17 decks)

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