GIT (gastro)

Question 1

What is celiac disease?

Answer 1

An autoimmune, malabsorption disease due to sensivity to gluten

Question 2

Manifestations of celiac disease

Answer 2

°Chronic or intermittent diarrhea
°Steatorrhea
°Stinking, bad smell/offensive stools
°Weight loss
°Iron deficiency anemia (or Folate or B12 deficiency)
°Manifestations of anemia (fatigue)

Question 3

Complications of celiac disease

Answer 3

Osteoporosis
T-cell lymphoma (rare)
Associated to dermatitis herpetiformis

Question 4

Diagnosis of celiac disease

Answer 4

First line: Positive TTG (tissue transglutaminase antibodies)+IgA
refered as tTG-IgA test.
sensivity of 98%
specificity of 95%

And Positive endomysial antibodies

Question 5

How does a celiac disease diagnosis be confirmed?

Answer 5

If tTG (+) then...
Jejunal or duodenal biopsy. 
(shows Villous atrophy, crypt hyperplasia, increased inter-epithelial lymphocyte)

***REMEMBER
For the biopsy to be accurate, introduce gluten SIX WEEKS before the biopsy!

Question 6

Celiac disease treatment

Answer 6

Gluten-free diet

Question 7

33YO male, non smoker. Presents with recurrent and chronic diarrhea for 6 months. His clothing appears to be ill-fitting. Hb 11 and MCV 105.

Most likely diagnosis?

Answer 7

Celiac disease.

Endoscopy+duodenal biopsy will show?
Villous atrophy

Question 8

Crohn’s disease endoscopy

Answer 8

Skip lesions, transmural (deep ulcers) and Cobblestone appearance.

Question 9

Crohn’s disease histology

Answer 9

Granuloma and increased Goblet cells.

Question 10

Crohn’s disease symptoms and examination

Answer 10

°Abdominal pain or mass on the right iliac fossa
°Usually non-bloody diarrhea
°Weight loss
°Perianal fistulas, fistulae
°Aphthous oral ulcers (more common in CD than UC)

Question 11

Histology of Ulcerative Colitis

Answer 11

Crypt abscesses

decreased goblet cells

Question 12

Barium enema in Ulcerative Colitis

Answer 12

°Loss of haustration

°Drain pipe appearance

Question 13

Symptoms and examination in Ulcerative Colitis

Answer 13

°Left lower quadrant pain (abdominal)
°Bloody diarrhea more common
°Primary Sclerosing Cholangitis is more common
°Aphthous oral ulcers (more common in CD)

Question 14

How does smoking affects CD and UC?

Answer 14

Smoking INCREASES the risk of CD

Smoking DECREASES the risk of UC (protective)

Question 15

Colonoscopy in Chrohn’s Disease

Answer 15

Cobble stone appearance, deep ulcers (transmural) and skip lesions

Question 16

Small bowel enema in CD

Answer 16

Kantor’s string sign (“refers to the string-like appearance of a contrast-filled bowel loop caused by its severe narrowing.”), thorn ulcers and fistulae

Question 17

Barium enema in UC

Answer 17

loss of haustral markings

Question 18

Crohn’s disease treatment

Answer 18

°Oral prednisolone (1st line to induce remission)
°Mesalazine

REMEMBER
Crohn’s=Corticosteroids

Question 19

Ulcerative Colitis treatment

Answer 19

5-ASA (Mesalazine) as 1st line to induce remission

Severe UC exacerbation = IV hydrocortisone

Question 20

Physiopathology of Barret’s Oesophagus

Answer 20

Prolonged hydrochloric acid reflux to the oesophagus.
The lower oeasophagus undergoes “METAPLASIA”
From Squamous to Columnar epithelium.
Tip: “Shampoo for children”

Question 21

Histology expected in Barret’s oesophagus

Answer 21

COLUMNAR metaplasia

can develop adenocarcinoma of the lower 1/3 of the oesophagus

Question 22

Cancer in achalasia vs cancer in Barret’s oesophagus

Answer 22

Achalasia= squamous cell carcinoma of the upper 2/3 of the oesophagus

Barret’s = adenocarcinoma of the lower 1/3 of the oesophagus. (common in GERD too)

Question 23

What is achalasia?

Answer 23

Inability to relax the lower oeasophageal sphincter (LOS) due to idiopathic loss of the normal neural structure

Question 24

Main symptom in achalasia

Answer 24

Progressive dysphagia to both solids and liquids

There might be weight loss and chest pain

Key word: regurgitation (also in pharyngeal pouch)

Question 25

Pharyngeal pouch symptoms

Answer 25

``` Regurgitation Halitosis (stale food or fluid) Gurgling sound in the chest when drinking A lump sensation in the throat Neck bulge ```

Question 26

Investigation of a patient with achalasia

Answer 26

X-ray: Megaoesophagus (dilated) Barium meal: Bird's beak appearance of the distal end of the oesophagus Oesophageal manometry: the most accurate, increased lower oeasophageal resting pressure

Question 27

Treatment of Achalasia

Answer 27

Dilation of the lower oeasophageal sphincter.

Question 28

45 YO woman presents with productive cough and moderate fever. She also complains of central chest pain, REGURGITATION of undigested food and DYSPHAGIA to both SOLIDS AND FLUIDS. The X-ray shows megaesophagus What is the most likely diagnosis?

Answer 28

Achalasia | productive cough and fever--> aspiration pneumonia from regurgitation

Question 29

Upper GI endoscopy diagnostic indications

Answer 29

``` Haematemesis/melaena Dysphagia Dyspepsia (>55yrs old+alarm symptoms or tx refractory) Duodenal biopsy (coeliac?) Persistent vomiting Iron deficiency (cancer?) ```

Question 30

Therapeutic indications of upper GI endoscopy

Answer 30

``` Treatment of bleeding lesions Variceal banding and schlerotherapy Argon plasma coagulation for suspected vascular abnormality Stent insertion, laser therapy Stricture dilatation, polyp resection ```

Question 31

Upper GI endoscopy pre-procedure and procedure

Answer 31

Stop PPIs 2 weeks preop (if possible--> pathology masking) Nil by mouth (ayuno) 6 hrs before Don't drive for 24 hrs if sedated Sedation optional with midazolam 1-5mg IV Propofol if deeper sedation is needed Nasal prong O2 Local anesthetic in the pharynx (optional) Continuous suction must be available

Question 32

Upper GI endoscopy complications

Answer 32

Sore throat Amnesia from sedation Perforation (0.1%) Bleeding (if on aspirin, clopidogrel, warfarin or Direct Oral Anti Coagulants= DOAC)

Question 33

Duodenal Biopsy in Upper GI endoscopy for....

Answer 33

Gold Standard in Coeliac disease | Useful in unusual causes of malabsorption (giardiasis, lymphoma, Whipple's disease)

Question 34

Sigmoidoscopy

Answer 34

PR (rectal examination) first! Views rectum+distal colon (approx splenic flexure) Flexible has displaced rigid for diagnosis of distal colon pathology BUT STILL ~25% of cancers remain out of reach Therapeuthic= decompression of sigmoid volvulus Preparation with phosphate enema PR DO BIOPSIES! macroscopic appearances may be normal! (Like amyloidosis and microscopic colitis)

Question 35

Diagnostic indications for colonoscopy

Answer 35

Rectal bleeding (when settled if acute) Iron-deficiency anaemia (bleeding cancer) Persistent diarrhoea Positive faecal occult blood test Assessment or suspicion of IBD (Inflammatory Bowel Disease) Colon Cancer Surveillance

Question 36

Therapeutic indications for colonoscopy

Answer 36

``` Haemostasis (eg. Clipping vessel) Bleeding angiodysplasia lesion (argon beaker photocoagulation) Colonic stent deployment (cancer) Volvulus decompression Pseudo-obstruction Polypectomy ```

Question 37

Preparation and procedure for colonoscopy

Answer 37

``` Stop iron 1 week prior Discuss with local endoscopy unit bowel preparation and diet DO PR (rectal exam) FIRST! Sedation and analgesia as in endoscopy ```

Question 38

Colonoscopy complications

Answer 38

Abdominal discomfort Incomplete examination Haemorrhage after biopsy or polypectomy Perforation (<0.1%) NO ALCOHOL and NO OPERATING MACHINERY FOR 24h!

Question 39

Video capsule endoscopy (VCE) uses

Answer 39

Evaluate obscure GI bleeding and detect small bowel pathology Use small bowel imaging or patency capsule ahead of VCE when px has abdominal pain or sugestion of small bowel obstruction

Question 40

Video capsule endoscopy (VCE) preparation and procedure

Answer 40

Clear fluids only the evening before then nil by mouth (ayuno) from morning until 4h after capsule is swallowed Capsule is swallowed and transmits video wirelessly to capture device worn by patient Normal activity can take place for the day

Question 41

Video Capsule Endoscopy (VCE) complications and problems

Answer 41

``` Capsule retention in <1% (endoscopic or surgical removal) Avoid MRI for 2 weeks after, unless AXR (abdominal X-Ray) confirms capsule has cleared Obstruction Incomplete exam (slow transit or achalasia) ``` No therapeutic options Poor localisation of lesions May miss subtle lesions

Question 42

Video Capsule Endoscopy (VCE) complications and problems

Answer 42

``` Capsule retention in <1% (endoscopic or surgical removal) Avoid MRI for 2 weeks after, unless AXR (abdominal X-Ray) confirms capsule has cleared Obstruction Incomplete exam (slow transit or achalasia) ``` No therapeutic options Poor localisation of lesions May miss subtle lesions

Question 43

Liver biopsy route and indications

Answer 43

Percutaneous if INR in range If not, transjugular with FFP (fresh frozen plasma) Increased enzymes (liver function test- LFT) of unknown aetiology. Assessment of fibrosis in chronic liver disease (now being replaced by ultrasound elastography) Suspected cirrhosis Suspected hepatic lesions/cancer

Question 44

Liver biopsy pre procedure, procedure and complications

Answer 44

Nil by mouth for 8h (ayuno) INR <1.5 and platelets >50x10^9/L Analgesia Under US/CT guidance Liver borders percussed--> where dullness is found in the mid-axillary line in expiration. Infiltrate lidocaine 2% down to the liver capsule Rehearse breathing and take needle biopsy with the breath held in expiration Lie on the right side for 2h, then in bed for 4h Pulse and blood pressure every 15 mins for 1h Then every 30 mins for 2h Hourly for 4h and discharge Complications: pain, pneumothorax, bleeding (<0.5%) and death (<0.1%)

Question 45

Causes of dysphagia

Answer 45

Mechanical: malignant stricture, benign structure, extrinsic pressure and pharyngeal pouch Motility disorders: achalasia, diffuse oesophageal spasm, systemic sclerosis, neurological bulbar palsy Other: oeasophagitis, globus (lump in throat=try to distinguish from true dysphagia)

Question 46

5 key questions of dysphagia

Answer 46

Difficulty swallowing solids and liquids from the start? Yes--> motility disorder (achalasia, CNS, pharyngeal causes) No --> solids then liquids = Stricture (benign or malign) Is it difficult to initiate swallowing movement? Yes= bulbar palsy, especially if patient coughs on swallowing Is swallowing painful? (Odynophagia) Yes= ulceration (malignancy, oeasophagitis, viral infection or Candida in immunocompromised, poor steroid inhaler technique) or spasm Intermittent dysphagia or constant and getting worse? Intermittent: suspect oesophageal spasm Constant and worsening: malignant stricture Does the neck bulge or gurgle on drinking? Yes: Pharyngeal pouch

Question 47

Signs in patients with dysphagia

Answer 47

Anaemia or cachectic? Examine mouth Feel for supraclavicular nodes (Virchow's node) Signs of systemic disease (systemic sclerosis or CNS disease)