GI Symptoms

Question 1

Aim of BMI

Answer 1

18.5-25

Control quantity more important than quality

Question 2

Advice given on diet

Answer 2

Base meals on starch 
Eat enough fruit and vegetables
DO NOT Eat foods high in fat, salt or sugar
Eat some meat, fish, eggs and beans
Eat some milk and dairy products
Moderate alcohol use: <14U/wk
Supplements for folic acid at least 12w, Vit D
Increase portions of Oily fish
Decrease refined sugar

Question 3

When should you avoid a diet?

Answer 3

<5yo
Need for low residue or specific diet
Wt loss is expected
Dyslipidaemia, DM, obesity, constipation
Liver failure, chr pancreatitis, renal failure
Inc BP

Question 4

Name 9 conditions you will find the in mouth

Answer 4

Leucoplakia
Aphthous ulcers
Candidiasis
Gingivitis
Microstomia
Oral pigmentation
Teeth
Tongue: glossitis, macroglossia, tongue ca

Question 5

What is Leucoplakia

Answer 5

White patch on the tongue

Question 6

What is an Aphthous ulcer

Answer 6

Shallow, painful ulcers on the tongue

Caused by: Crohn’s coeliac trauma, lichen, infections

Question 7

What is cheilitis

Answer 7

Angular stomatitis: fissuring of the mouth’s corners due to denture, candidiasis or Fe/Vit B12 deficiency

Question 8

What are the tests for Dysphagia?

Answer 8

FBC: anaemia
U+E: dehydration
CXR: mediastinal fluid
Upper GI endoscopy +/-1 biopsy
Video fluoroscopy

Question 9

What are the specific conditions that contribute to dysphagia?

Answer 9

Oesophagitis
Diffuse oesophageal spasm
Achalance
Benign oesophageal stricture
Oesophageal ca
CNS causes

Question 10

Specific tests for Nausea and Vomiting

Answer 10

Ca, glucose, amylase
ABG: exclude hypochloraemia
Plain AXR: to exclude bowel obstruction
Upper GI endoscopy: if persistent vomiting

Question 11

What does it mean if N+V

a) At morning
b) 1h post food
c) Preceded by loud gurgling
d) Vomiting that relieves pain

Answer 11

a) Pregnancy or ICP
b) Gastric stasis/gastroparesis
c) GI obstruction
d) Peptic ulcer

Question 12

What are the symptoms of dyspepsia

Answer 12

Epigastric pain related to hunger
\+/- bloating
Fullness after meals
Heartburn
ALARM symptoms
A – anaemia
L – Loss of weight
A – Anorexia
R – Recent onset / progressive symptoms
M – melaena / Haematemesis
S – swallowing difficulty

Question 13

Rx for dyspepsia

Answer 13

Lifestyle: remove stress
H. pylori eradication: triple therapy x4w
Drugs to reduce acid: PPIs, H2 blockers
Drug-induced ulcers: stop the drugs

Question 14

Name 3 types of diarrhoea

Answer 14

Steatorrhoea: fatty, increased gas, offensive smell, floating, hard-to-flush stools (giardiasis, coeliac)
Watery: osmotic (laxative induced), secretory or functional (IBS)
Inflammatory discharge: blood and pus (Crohn’s, UC, bacteria, parasites)

Question 15

What are the risk factors for acute diarrhoea

Answer 15

<2w = suspect gastroenteritis
HIV
Achlorhydria
Acid suppressants
Travel
Diet change

Question 16

What are the risk factors for chronic diarrhoea

Answer 16

Diarrhoea alternates with constipation = IBS

Wt loss / nocturnal / anaemia = UC / Crohn’s

Question 17

What causes bloody diarrhoea

Answer 17

Campylobacter
Shigella / Salmonella
E.coli
UC/Crohn’s 
Colorectal ca
Polyps

Question 18

What causes Mucus

Answer 18

IBS
Colorectal ca
Polyps

Question 19

What causes frank pus

Answer 19

IBD, diverticulitis, firstula / abscess

Question 20

What causes explosive diarrhoea

Answer 20

Infectious: cholera / giardia / yersinia / rotavirus

Question 21

What are the signs and symptoms in diarrhoea

Answer 21

Dehydration (dry mucous membranes, dec skin turgor)
Increased CRT = shock
Fever / wt loss / clubbing / anaemia / oral ulcers / rashes or abdo mass/scars
Goitre / hyperthyroid signs

Question 22

What are the criteria for constipation?

Answer 22

Rome criteria – >2 symp during bowel movements (BM)

• Straining for >25% of BMs
• Lumpy or hard stools in >25% of BMs
• Sensation of incomplete evacuations for >25% BMs
• Sensation of anorectal obstruction or blockage for >25% of BMs
• Manual manoeuvres to facility at least 25% of BMs
• Fewer than 3BMs for week

Question 23

What questions do you ask the pt who is constipated?

Answer 23

Frequency, nature, consistency of stools
Blood / mucus?
Diarrhoea alternating with constipation
Pain
Diet
Drugs

Question 24

What are the tests for constipation?

Answer 24

Blood: FBC, ESR, U+E, Ca2), TFT
Sigmoidoscopy
Ba enema / colonoscopy

Question 25

What is the Rx of constipation

Answer 25

Drink + diet/exercise Senna +/- bulking agent lactulose, Ispaghula husk, methylcellulose, sterculia Stimulant laxative: increase intestinal motility, senna, bisacodyl, glycerol Stool softeners: arachis oil, liquid paraffin Osmotic laxatives: lactulose, Mg or Na salts, Phosphate enemas Mdt

Question 26

Name the types of Jaundice

Answer 26

``` Pre-hepatic Hepatocellular Cholestatic/obstructive Conjugated Unconjugated ```

Question 27

What are the specific tests of Jaundice

Answer 27

Urine: bilirubin Bloods: FBC, clotting, film, reticulocyte count, Coomb’s test, haptoglobins, malaria parasites, Paul Bunnel (EBV) Chem: U+E, LFT, ALT, AST, alk phos, ggt, total protein, albumin, paracetamol level Microbiology: leptospira, hep a, b, c Radio: US, ERCP, MRCP, Liver biopsy, CT/MRI

Question 28

Name common causes of Upper GI bleeding

Answer 28

``` Peptic ulcers Mallory-Weiss tear Oesophageal varices Gastritis/gastric erosions Drugs: NSAIDs, aspirin, steroids, thrombolytics, anticoagulants Oesophagitis Duodenitis Malignancy ```

Question 29

Rare causes of Upper GI bleeding

Answer 29

``` Bleeding disoders Portal HT gastropathy Aorto-enteric fistula Angiodysplasia Haemobilia Meckel’s diverticulum Peutz-Jeghers syndrome Osler-Weber-Rendu syndrome ```

Question 30

What are the criteria for GI bleeds?

Answer 30

``` Age Shock: systolic BP + pulse rate Comorbidity Post endoscopy diagnosis Signs of recent haemorrhage ```

Question 31

How do u manage GI bleeds?

Answer 31

2 large bore IV cannulae: FBC, U+E, LFT, clotting, give blood crossmatched/fluids Urine catheter, monitor ourly urine output CXR, ECG, ABG ?CVP line to monitor and guide fluid replacement Ransfuse until haemodynamically stable Correct clotting abnormalities Monitor pulse, bp, cvp Omeprazole Urgent endoscopy 4h later: re-examine + ?FFP + ?Hb >100gL Nil by mouth

Question 32

What is cirrhosis?

Answer 32

Irreversible liver dmg, where hepatic architecture is lost with bridging fibrosis and nodular regeneration

Question 33

What are the signs of cirrhosis – chronic liver disease?

Answer 33

``` Leuconychia (from hypoalbuminaemia) Terry’s nails Clubbing Palmar erythema Hyperdynamic circulation Dupuytren’s contracture Spider naevi Xanthelasma Gynaecomastia Atrophic testes Loss of body hair Parotid enlargement Hepatomegaly ```

Question 34

Complications of Hepatic failure

Answer 34

``` Coagulopathy, encephalopathy + confusion/coma Hypoalbuminuria: oedema, leukonychia Sepsis: pneumonia, septicaemia Spontaneous bacterial peritonitis hypoGly ```

Question 35

Complications for portal HT

Answer 35

Splenomegaly Portosystemic shunt incl oesophageal varices Caput medusae

Question 36

What are the specific tests for Cirrhosis | - What inc in these tests?

Answer 36

``` LFT: bilirubin, AST, ALT, Alk phos, gammaGT - All increase Hypersplenism seen: dec WCC + dec platelets + dec albumin =/- inc INR Ferritin, Iron/total Fe-binding capacity Hepatitis serology Immunoglobulins Autoantibodies (ANA, AMA, SMA) Alpha-feto protein Caeruloplasmin Alpha-antitrypsin Liver US + duplex: small liver or hepatomegaly, splenomegaly, focal liver lesions, hepatic vein thrombus, asicits MRI: caudate lobe size inc Ascitic tap for MC+S, neutrophils Liver biopsy ```

Question 37

General management for cirrhosis

Answer 37

``` Good nutrition Alcohol absintence Avoid NSAIDs, sedatives, opiates Colestyramine Consider US +/- alpha-fetoprotein every 3-6mo ```

Question 38

Specific management for cirrhosis

Answer 38

``` High dose ursodeoxycholic acid in PBC Penicillamine in Wilson’s If ascites: - Bed rest - Fluid restriction - Low-salt diet - Spironolactone 100mg/24h - Chart daily wt + wt loss - Add furosemide <120mg/24h - U+E If spontaneous bacterial peritonitis - Cefotaxime or tazocin - Metronidazole until sensitivities known ```

Question 39

Causes of cirrhosis

Answer 39

Chronic alcohol abuse Chronic HBV or HCV infection Genetic: Wilson’s, alpha1 antitrypsin deficiency, haemochromatosis Hepatic vein events (Budd-Chiari) Non-alcoholic steatohepatitis (NASH) Autoimmunity: PBC, Primary sclerosing cholangitis, autoimmune hep Drugs: amiodarone, methyldopa, methotrexate

Question 40

What is the grading system of Cirrhosis?

Answer 40

To evaluate the risk of variceal bleeding | Child-Pugh grading

Question 41

What is the link of cirrhosis to deteriorating renal function

Answer 41

Decrease hepatic clearence of immune complexes lead to trapping in kidney Thus IgA nephropathy +/- hepatic glomerulosclerosis