GI - Large and small intestine Flashcards
1
Q
what is intestinal failure
A
when the gut can no longer supply hydration and nutritional needs of body - failure of ability to absorb food via intestines
2
Q
what is type 1 intestinal failure associated with
A
short term - post op, chemo
3
Q
what qualifies as acute intestinal failure
A
lasting 2 weeks
type 1 and type 2
4
Q
what is type 2 intestinal failure associated with
A
sepsis abdo fistula /Crohns metabolic comp ischaemia prolonged surgery comps
5
Q
what is the treatment of acute intestinal failure
A
parenteral nutrition if unable to tolerate food/fluid - 7 days post op but allow as much enteral feeding as possible
PPI
Octreotide (reduced bowel movements)
alpha-hydroxycholecalciferol (preserves Mg)
6
Q
what is type 3 intestinal failure
A
chronic - SBS
7
Q
what length of bowel qualifies as SBS
A
< 200cm functioning small bowel
8
Q
what is the treatment of chronic SBS
A
home parenteral nutrition
PPI
if venous access lost or liver disease - transplant
9
Q
what are some complications of parenteral nutrition
A
pneumothorax arterial puncture misplacement endocarditis (venous lines) hepatitis (venous lines)
10
Q
where is access for parenteral nutrition gained
A
via subclavian/internal jugular vein - US guided
11
Q
what nutrient deficiencies is referring syndrome associated with
A
hypokalaemia
hypophosphataemia
hypomagnesaemia
12
Q
what is referring syndrome
A
imbalances in fluid and electrolytes leading to cell/organ damage
13
Q
what can refeeding syndrome result in
A
arrhythmia
CF
death
14
Q
what are some s/s of small bowel obstruction
A
intermittent episodes of colicky pain absolute constipation - no flatus/burping abdominal distension faeculent vomiting high pitched/tinkling bowel sounds (like water against a boat) obstruction may be palpable lack of abdo tenderness visible peristalsis
15
Q
if copious volumes of bile stained fluid was vomited where would you suspect the obstruction was
A
upper small bowel
16
Q
if semi-digested food eaten half a day ago was vomited where would you suspect the obstruction was
A
gastric outlet
17
Q
how does bowel obstruction look on an investigation
A
dilation of bowel proximal to the obstruction and collapsed bowel distal
18
Q
what are the investigations for bowel obstruction
A
supine AXR - looks for distension
CT - confirm and look for cause
19
Q
what is the treatment of bowel obstruction
A
NBM cannula - take blood and IV fluids NG tube to decompress stomach (drip and suck) anti embolism measures
20
Q
what are some causes of bowel obstruction
A
congenital tumour hernia - abode wall/internal volvulus post op comp strictures - Crohn's, Diverticular (usually incomplete) intususceptioin GS ileus adhesions
21
Q
what is strangulation of the bowel
A
twisting of bowel in loops around itself cutting off blood supply
22
Q
what does strangulation of the bowel lead to
A
progresses to infarction and perforation due to arterial inflow compromise
23
Q
what are some s/s of strangulation
A
constant pain "pain over hernia" - can occur in external hernia or volvulus sepsis/shock MSO failure death
24
Q
what is the treatment of strangulation
A
urgent surgery
25
how is perforation of bowel diagnosed
erect CXR - free subphrenic gas
| CT may help find source
26
what is paralytic ileus
Obstruction of the intestine due to paralysis of the intestinal muscles
27
what are the s/s of paralytic ileus
similar to obstruction but tinkling bowel sounds and pain less common
28
what is the treatment of paralytic ileus
drip and suck while awaiting restoration of peristalsis
29
what is pseudo-obstruction (ogilvie's syndrome)
acute dilation of colon in absence of colonic obstruction in acutely unwell patients
30
```
what bowel obstruction is associated with
hip replacement
CABG
spinal anaesthesia
pneumonia
frail/eldering
```
pseudo-obstruction
| ogilvie's syndrome
31
how is pseudo-obstruction diagnosed
AXR +/- CT
| confirms gaseous distension proximal to distal rectum
32
what may be required in pseudo-obstruction
colon may require colonscopic decompression
33
when is surgery done early in SBO
strangulation
ischaemia
perforation
to prevent dead guts
34
what does acute mesenteric ischaemia usually affect
small bowel
35
why is the large bowel less commonly affected by acute mesenteric ischaemia
marginal artery of drummond
36
what are some s/s of acute mesenteric ischaemia
```
elderly
acute severe abdominal pain
poorly localised
cramping
rapid hypovolaemia --> shock
reduced bowel sounds
```
37
true/false
| acute mesenteric ischaemia is associated with AF
true
38
what are some causes of acute mesenteric ischaemia
volvulus
SMA thrombosis/embolism
mesenteric vein thrombus - affects smaller lengths of bowel
low flow states - poor CO, post cardiac surgery, renal failure
39
what are some complications of acute mesenteric ischaemia
gangrene
translocated bacteria across dying gut wall
septic peritonitis
MODS
40
what is the treatment of sepsis caused by acute mesenteric ischaemia
fluids
| gentamicin + metronidazole + heparin
41
what is the treatment of acute mesenteric ischaemia
surgery to remove dead bowel
| revascularisation - arteriography + thrombolysis
42
what are some tests for acute mesenteric ischaemia
```
increased Hb
increased WCC
increased plasma amylase
AXR - gasless abdomen
CT/MRI angiography
```
43
what gut layer is most sensitive to ischaemia
mucosa - most metabolically active
44
what is chronic mesenteric ischaemia also known as
intestinal angina
45
what are some s/s of chronic mesenteric ischaemia
```
severe, colicky post prandial abdominal pain
weight loss
upper abdominal bruit
+/- PR bleeding
malabsorption
N+V
```
often Hx vascular disease
46
how is chronic mesenteric ischaemia diagnosed
CT/MR angiography
| Doppler US
47
what is the treatment of chronic mesenteric ischaemia
surgery
percutaneous transluminal angioplasty
stent (palliative)
48
what are some complications of chronic mesenteric ischaemia
scarring and fibrosis --> stricture
gangrene
perforation
49
what is ischaemic colitis
chronic colonic ischaemia
50
where does ischaemic colitis most commonly affect
sigmoid colon
51
who does ischaemic colitis affect
elderly
| those at risk of atherosclerosis
52
what are some s/s of ischaemic colitis
lower left sided abdominal pain
| +/- bloody diarrhoea
53
what does ischaemic colitis look like on a barium enema
THUMB PRINTING OF SUBMUCOSAL SWELLING AT SPLENIC FLEXURE
54
what are some investigations for ischaemic colitis
colonoscopy + biopsy - gold standard
CT
barium enema
55
what is the histological appearance of ischaemic colitis
withering of crypts
pink smudgy lamina propria
fewer chronic inflammatory cells
56
how is ischaemic colitis caused and what can is progress to
low flow in IMA
mild ischaemia
gangrenous colitis
peritonitis/hypovolaemia shock
57
what is the treatment for ischaemic colitis
fluids and antibiotics
| resection of affected bowel (gangrenous colitis) + stoma
58
true/false
| strictures are common in ischaemic colitis
true
59
what is volvulus and what does it cause
twisting of bowel along mesentery - cause of acute mesenteric ischaemia
obstruction and disruption of blood flow --> infarction --> gangrene
60
where does volvulus affect elderly
sigmoid
61
where does volvulus affect young adults
caecum
62
how is volvulus diagnosed
AXR
63
what is the treatment of volvulus
flatus tube + sigmoidoscope (removes flatus and fixes volvulus)
surgical resection
64
what is intussusception
part of intestine invaginate into another section of intestine
often causing obstruction
65
what is the most common cause of intussusception in children (emergency)
lymphoid hyperplasia due to rotavirus in terminal ileum
| leads to intussusception in caecum (ileocaecal junction)
66
what are the s/s of intussusception
current jelly stool/red currant stool
| bullseye appearance on US
67
what is the most common cause of intussusception in adults
tumour
68
what is a diverticulum
mucosal herniation through muscle coat usually at sites of arterial perforation - out pouching of gut wall
69
what is a true diverticulum
involves all layers of the gut wall
70
what is a false diverticulum
just mucosa and serosa
71
where are diverticula most commonly found
sigmoid colon
72
how is diverticulosis diagnosed
incidental finding on endoscopy
73
what is diverticulitis
inflammation of diverticulum e.g. from blockage - food, seeds
74
what is the cause of diverticulum
low fibre diet - high intraluminal pressures and stool more liquid so higher pressure contractions needed
75
what classification is used for acute diverticulitis
hichney
76
what are some s/s of diverticular disease
```
LIF pain/tenderness
relieved by defecation
nausea
flatulence
if diverticulitis - pyrexia, increased WCC CRP and ESR
```
77
what are some investigations for diverticular disease
sigmoidoscopy
Ba enema
CT - first line for diverticulitis
78
what are some complications of diverticular disease
```
fistula
stricture
pericolic abscess
haemorrhage - rectal bleeding
perforation - shock
sepsis
```
79
what is the most common fistula associated with diverticular disease
colovesical - bladder
80
what is the treatment of diverticular disease
fluids/rest/oral ABs
if complicated:
Percutaneous drainage
Hartmann's procedure
81
what is Hartmann's procedure
remove sigmoid colon and attach colostomy bag to descending colon
82
is meckel diverticulum true or false
true
83
what is meckel diverticulum
distal ileum contains embryonic remnants of gastric and pancreatic tissue due to the incomplete regression of the vitello-intestinal duct - gastric acid secretion
84
where does meckel diverticulum occur
60cm from ileocaecal valve
85
what are some s/s meckel diverticulum
pain
rectal/faecal bleeding
can mimic appendicitis
86
when does meckel diverticulum usually present
1st 2 years of life
87
how is meckel diverticulum diagnosed
Technicium Tc 99M scan
88
what kind of inflammation if crohn's
transmural
89
where does crohn's affect
any part of GI tract from mouth to anus
90
where is Crohn's most commonly seen
terminal ileum
| proximal colon
91
how do strictures form in Crohn's
omentum (fat) wrapping around bowel
92
is Crohn's inflammation continuous
no - skip lesions
93
what is the appearance of Crohn's
cobblestone mucosa
| deep fissuring ulcers
94
what happens to the colon walls in Crohn's
thickened
95
are granulomas seen in Crohn's
yes
| non-caseating granulomas
96
what are some causes of Crohn's
smoking
infection
NSAIDs
97
what gene is mutated in Crohn's
NOD2 (IBD-1) - on C16 - encodes protein involved in bacterial recognition
CARD15
98
what immune cells mediate Crohn's
TH1
| - ILN, TNF, macrophages
99
who does Crohn's affect
20 - 40 yos
100
does Crohn's affect men or women more
men
101
what is the treatment of Crohn's
Steroids - short course, high dose
Immunosuppressants - maintenance
Anti-TNF
102
name 3 steroids used in Crohn's
prednisolone (oral)
budesonide (oral)
hydrocortisone
103
name 2 immunosuppressant used in Crohn's
azathioprine
| methotrexate
104
name 2 anti-TNF therapies used in Crohn's
| antibodies to TNF
infliximab - IV - chimeric
| adalimumab - SC - humanised
105
what are some complications of Crohn's
```
bowel obstruction
abscess
Fistula
Malabsorption
Stricture
Perforation
SBS
osteomalacia
malnutrition
amyloidosis
```
106
are extra GI symptoms common or rare in Crohn's
rare
107
what extra GI symptoms might be seen in Crohn's
clubbing
| skin/joint/eye problems
108
what is the risk of developing CRC from Crohn's
moderate
109
true/false
| there may be a RIF mass in Crohn's
true
110
how is Crohn's diagnosed
endoscopy + barium imaging of SB
CT, MRI, Colonoscopy
Technetium labelled white cell scan
111
what would the bloods of Crohn's look like
raised CRP, albumin, platelets, B12, ferritin
112
is surgery for Crohn's curative
no
113
what are the s/s Crohn's in the SB
periumbilical abdominal cramps
diarrhoea
weight loss
114
what are the s/s Crohn's in the colon
lower abdominal cramps
| diarrhoea + blood
115
what are the s/s Crohn's in the mouth
ulcers
angular chelitis
swollen lips
116
what are the s/s Crohn's in the anus
peri-anal disease - recurrent abscess formation leading to fistula with persistent leakage and damaged spinchters
pain
117
what is a technetium labelled white cell scan
a means of detecting infection in bone joints and soft tissue as well as inflammation due to other causes such as IBD
118
what does elevated ESR indicate
presence of inflammation
119
what is ESR
rate at which red blood cells settle out in a tube of unclotted blood mm/hr
120
what is intermediate colitis
overlap of Crohn's and UC
121
what is Rigler's sign
air on both luminal and peritoneal side of bowel wall - perforated ulcer
122
what are the side effects of corticosteroids
```
avascular necrosis
osteoporosis/growth failure
acne
thinning of skin
weight gain/increased appetite
diabetes
hypertension
cataracts
```
123
why does budesonide not have many systemic side effects
undergoes 1st pass metabolism in liver
124
what are some side effects of azathioprine
hepatitis
pancreatitis
skin cancer
leukopenia (FBR)
125
what drug should be avoided with azathioprine
allopurinol
126
what is the onset of azathioprine like
slow
127
what do the letters in SNAP stand for
Sepsis
Nutrition
Anatomy
Plan
128
what is measured before azathioprine is prescribed and why
TMPT levels - people with TMPT enzyme problems are more susceptible to infections as azathioprine lowers the WCC - TMPT is responsible for converting some of 6-MP into 6-MMP - if not working/not present higher levels of ^-TGN (active form of azathioprine) - more likely to reduce WCC
129
how does Anti-TNF work
promotes apoptosis of activated T-lymphocytes
130
what type of inflammation is seen in UC
mucosal inflammation
131
is UC inflammation continous
yes
132
where is UC seen
rectum and extends proximally to colon
133
who does UC affect
non-smokers
| 20-30 yos and elderly
134
does UC affect men or women more
men
135
what immune cells mediate UC
Th1 and Th2
136
how is severe US classified
```
> 6 bloody stools in 24 hours
+1 of
Fever
Anaemia
Tachycardia
Elevated ESR
```
Truelove + Witt Criteria
137
what kind of things aggravate UC
NSAIDs
infection
ABs
138
is the risk of CRC greater in Crohn's or UC
UC
139
are there granulomas in UC
no
140
what are some characteristics of UC
```
Cryptitis / Crypt abscesses
loss of haustra
thin walled
granular mucosa
absence of goblet cells
superficial ulceration
```
141
what is the disease extent of proctitis
rectum - no more proximal than sigmoid colon
142
what is the disease extent of left sided colitis
rectum and left colon - no more proximal than splenic flexure
143
what is the disease extent of pancolitis
rectum and entire colon
144
what is seen in the bloods of UC
CRP
| Albumin
145
what is seen in an AXR of UC
stool absent from inflamed colon
| toxic megacolon
146
how is UC diagnosed
Endoscopy + biopsy
147
what is seen on endoscopy of UC
loss of vessel pattern
contact bleeding
pseudopolyps
148
what is the treatment of UC
5ASA (mesalazine)
steroids
immunosuppressants
Anti-TNF
149
is surgery of UC curative
yes
150
what are 2 options of surgery in UC
permanent ileostomy
| restorative proctocoloectomy + pouch
151
what are some s/s UC
```
diarrhoea + bleeding
increased bowel frequency
urgency
tenesmus
incontinence
night rising
lower abdominal pain (LIF)
```
152
what are some complications of UC
```
CRC
cholangiocarcinoma
anaemia
shock (bleeding)
toxic megacolon
```
153
how does UC lead to CRC
chronic inflammation --> dysplasia --> carcinoma
154
is UC or Crohn's associated with PSC
UC
155
what is the surgical treatment of duodenal or pyloric stenosis
gastrojejunostomy
156
what is amyloidosis
deposition of abnormally folded protein
157
are extra-GI symptoms common in UC
yes
158
what are some extra-GI symptoms of UC
```
erythema nodosom
joint/eye/skin problems
ankylosing spondylitis
steatosis
gall stones
episcleritis
iritis
sacriolitis
malnutrition
clubbing
pyoderma
```
159
true/false
| 5ASA reduces risk of CRC
true
160
what are some side effects of 5ASA
diarrhoea
| idiosyncratic nephritis
161
how can 5ASA be administered
topical
enema
suppositorie (oral) - drug coated to delay release of drug until in bowel
162
why are topical 5ASAs inserted up rectum
- to avoid systemic side effects - 1st pass metabolism in liver meaning very little of drug exits into systemic circulation
163
what has better mucosal adherence
| suppositorie or enema
suppositorie
164
what is better at reaching sigmoid colon
| suppositorie or enema
enema
165
what is the Rome III criteria for IBS
```
recurrent abdominal pain for atleast 3 days / month for 3 months
+2 of
- improvement on defecation
- change in stool frequency
- change in stool form
```
166
what are some triggers of IBS
```
bread/fibre
infection
drugs e.g. opiates
menstruation
physiological factors
```
167
what are some s/s of IBS
```
abdo pain
change in stool frequency
change in stool form
improvement of pain on defecation
urgency
tenesmus
bloating/distension
mucus PR
worsened by stress
exaggerated gastro-colic reflex
```
168
what is IBS associated with
visceral hypersensitivity
| fibromyalgia, chronic fatigue syndrome/depression, TMS dysfunction, chronic pelvic pain
169
is IBS worse in men or women
women - oestrogen driven disease
170
when should a person with suspected IBS get an endoscopy
>55
Fhmx CRC
red flags e.g. waking up with need to dedicate, recent onset, rectal bleeding, weight loss, anaemia
171
what are some investigations done in IBS
FBC (anaemia)
| ESR/plasma viscosity/CRP/TTG
172
what is the treatment of IBS
```
reduce fibre/dairy/gluten
stop opiates e.g. codeine
antidiarrhoeals - loperamide
antispasmodics - buscopan, mebeverine, hyoscine
antidepressants - amitryphylline
```
173
what is a SE of amitryphylline
drowsiness - take at night, resets nerves in bowel
174
what is the treatment for constipation in IBS
movicol
175
what genes trigger coeliac disease
HLA-DQ2 and HLA-DQ8
176
what antibodies are present in coeliac disease
antiendomesial anti-gliadin Abs
| IgA anti-tissue transglutaminase Abs
177
what type of hypersensitivity reaction is coeliac disease
type IV
178
what immune cells are responsible for coeliac disease
Helper T cell mediated - mediate tissue damage following presentation by antigen presenting cells via MHC class II
179
what happens in coeliac disease
```
immune reaction (T cells) to gliadin in wheat fluid/gluten in small intestine (proximal)
gluten specific T cells produce IFN-Y which triggers intraepithelial lymphocytes and kills epithelial cells
damages enterocytes and reduces absorptive capacity
```
180
what is seen in the histology of coeliac disease
flat duodenal mucosa (villous atrophy)
181
what does loss of villous structure in coeliac disease cause
loss of absorptive SA
reduction in absorption
- malabsorption
182
what nutrients are malabsorbed in coeliac disease
```
CHOs
fats
AAs
water
electrolytes
vitamins
Fe, B12, folate
```
183
what are some s/s coeliac disease
```
abdominal distension
diarrhoea
failure to thrive (children)
bloating
dermatitis herpetiformis
flatulence
anaemia
steatorrhoea
```
184
what childhood disorder is coeliac disease associated with
childhood diabetes
| - think of MH
185
what is the treatment of coeliac disease
gluten free diet - damage is reversible
186
how is coeliac disease diagnosed
duodenal biopsy after a positive tTGA test (patient still eating gluten)
187
what are some complications of coeliac disease
T cell lymphoma
Small bowel carcinoma
gallstones
188
what causes lactose intolerance
decreased function of lactase enzyme
189
where is lactase enzyme found
brush border of enterocytes
190
what does lactase normally break down
lactose into glucose and galactose
191
what are some s/s of lactose intolerance
flatulence
distension
diarrhoea
following lactose consumption
192
what causes the s/s of lactose intolerance
presence of lactose in colon --> colonic flora produce CO2, H2 and methane
193
what is a test for lactose intolerance
H2 breath test
194
what inheritance in congenital lactose intolerance
rare AR disorder
195
why can small bowel infection cause lactose intolerance
lactase susceptible to injury
196
what is colonic angiodysplasia
submucosal lakes of blood
197
what causes colonic angiodysplasia
vascular malformation
198
where is colonic angiodysplasia usually seen
right colon
199
how is colonic angiodysplasia diagnosed
CT angiography
| colonoscopy
200
how is colonic angiodysplasia treated
embolisation
endoscopic ablation - cauterising bleeding BVs
surgical resection
201
what is a complication of cauterising bleeding blood vessels
ischaemia
202
what are 5 types of colitis
```
ischaemic
collagenous
lymphocytic
radiation
pseudomembranous
```
203
how is colitis diagnosed
AXR
stool culture
sigmoidoscopy
Ba enema
204
how is colitis treated if the cause is IBD
IV fluids
IV steroids
GI rest
205
what are some s/s colitis
```
diarrhoea +/- blood
abdo cramps
dehydration
sepsis
weight loss
anaemia
```
206
what causes collagenous colitis
NSAIDs
207
is collagenous colitis seen grossly
no - microscopic
208
what is seen in the histology of collagenous colitis
thickened basement membrane (basal lamina of epithelial cells)
intraepithelial inflammatory cells
209
what are some s/s of collagenous colitis
watery diarrhoea
| normal endoscopy
210
is lymphocytic colitis seen grossly
no - microscopic
211
is there thickening of BM in lymphocytic colitis
no
212
are there architectural changes in either of the microscopic colitis'
no
213
what is seen in lymphocytic colitis
increased intraepithelial lymphocytes
| - possibly linked to coeliac
214
what causes radiation colitis
cancer treatment
215
what is seen in radiation colitis
telangectasia - thread like read lines on skin
216
what is seen histologically in radiation colitis
Bizarre stroll cells
| bizarre vessels - thick walled
217
what causes pseudomembranous colitis
broad spectrum antibiotics that clear normal flora in colon causing subsequent C. Diff attack
218
what toxins are produced by C diff
toxin A and B
219
what is the treatment of pseudomembranous colitis
```
asymptomatic - none
metronidazole
+ vancomycin if severe
may need colectomy
may be fatal
```
220
what are the s/s of pseudomembranous colitis
diarrhoea + bleeding
221
what is seen in pseudomembranous colitis
patchy membranes stick to mucosa throughout colonic wall
volcano like fibrinopurulent exudate lesions
flame thrower like
222
what are the 4 Cs associated with C diff infection
ciprofloxacin
clindamycin
co-amoxiclav
cephalosporins e.g. ceftriaxone
