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1B Gastroenterology > Lower GI tract > Flashcards

Lower GI tract Flashcards

1
Q

what is the anatomy of the large intestine?

A
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2
Q

what are the arteries and veins of lower GI tract?

A
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3
Q

what does the inferior mesenteric artery supply?

A

left side of the colon

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4
Q

what area is under parasympathetic control?

A
  • Ascending colon and most transverse colon in innervated by vagus nerve
  • More distal innervated by pelvic nerves
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5
Q

what area is under sympathetic control?

A

lower thoracic and upper lumbar spinal cord

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6
Q

what is the external anal sphincter controlled by?

A

somatic motor fibres in pudendal nerves (S1,S2,S3)

afferent sensory neurons detect pressure- send signals for emptying of rectum

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7
Q

what does the enteric nervous system do?

A

pace maker in the bowel

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8
Q

what disease is caused by lack enteric nervous system?

A

Hirschsprung’s disease

no enteric intramural ganglia

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9
Q

where is the myenteric plexus ganglia located?

A

concentrated below taenia coli

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10
Q

what are lower GI disorders split into?

A

inflammatory

infective

structural

functional

neoplastic

other

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11
Q

what inflammatory lower GI disorders are there?

A

inflammatory bowel disease (IBD)

microscopic colitis

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12
Q

what are the infective lower GI disorders?

A

C.Diff

E. Coli

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13
Q

what are the structural lower GI disorders?

A

diverticular disease

hemorrhoids

fissures

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14
Q

what are the functional lower GI disorders?

A

irritable bowel syndrome

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15
Q

what are the neoplastic lower GI disorders?

A

colonic polyps and colon cancer

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16
Q

what are the other lower GI disorders?

A

neurological

metabolic

vascular

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17
Q

what are the subsets of inflammatory bowel disease?

A

Ulcerative colitis (UC) and Crohn’s disease (CD)

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18
Q

what are the concepts of ulcerative colitis?

A
  • Inflammatory disorder limited to the colonic mucosa
  • Superficial layer
  • Continuous
  • Always involves the rectum
  • M = F
  • NO granulomas
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19
Q

what are the types of ulcerative colitis?

A
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20
Q

what are the features of chron’s disease?

A
  • Can affect any part of the gastrointestinal tract
  • Patchy chronic transmural granulomatous inflammation
  • Tendency to form fistula or strictures
  • F>M (1.5:1)
  • Hallmark = ulceration
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21
Q

what is a fistula?

A

penetration from deep inflammation between 2 different walls

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22
Q

what is a stricture?

A

narrowing of lumen due to inflammation and oedema

form fibrous tissue that does not open up again

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23
Q

what are the types of crohn’s disease?

A
24
Q

what are the symptoms of UC and Crohns?

A

depends on site of inflamation

  • Colitis
    • Bleeding
    • Mucus
    • Urgency
    • Diarrhoea
  • Perianal (crohn’s disease only)
    • Anal pain
    • Leakage
    • Difficulty passing stool
  • Small bowel disease (crohn’s disease only)
    • Abdominal pain
    • Weight loss
    • Tiredness/lethargy
    • Diarrhoea
    • Abdominal mass
25
Q

what are some extra-intestinal manifestations of IBD?

A
  • Arthritis
    • Axial – Ankylosing Spondylitis
    • Peripheral
  • Skin
    • Erythema nodosum
    • Pyoderma gangrenosum
  • Eyes
    • Anterior uveitis
    • Episcleritis/Iritis
  • Liver
    • Primary Sclerosing Cholangitis (PSC)
    • Autoimmune hepatitis
26
Q

what is the aetiology of IBD?

A

combination of impaired mucosal immune response to the gut microbiota in a genetically susceptible host

imbalance between pathological and healthy microbiota

27
Q

what is the genetic susceptibility to IBD?

A

NOD2

HLA

ATG

IL23R

28
Q

what is the immune response causing IBD?

A

Anti-saccharomyces cervisiae (ASCA)- Crohn’s

pANCA-UC

29
Q

what other environmental factors may contribute to the formation of IBD?

A

luminal microbes

(mycobacterium paratuberculosi)

30
Q

what affect does diet have on IDB?

A

unhealthy food= change microbiota causing dysbiosis (unhealthy microbiota)

31
Q

what is the effect of appendectomy on IBD?

A

protection from UC but can develop Crohn’s disease

(appendix is a store of microbiota)

32
Q

what is the effect of smoking on IBD

A

protective against UC

makes Crohn’s worse

33
Q

what is the effect of hygiene on IBD

A

high hygiene can develop IBD

34
Q

what is dysbiosis?

A

development of poor and unbalanced bacterial communities in gut lumen

pathologies= autoimmunity,allergy, metabolic disorders

35
Q

what is the management for IBD?

A
  • Induce clinical remission
  • Maintain clinical remission
  • Improve patient quality of life
  • Heal mucosa
  • Decrease hospitalisation/ surgery & overall cost
  • Minimise disease and therapy related complications
36
Q

what drugs can be used to treat IBD?

A
  • Steroids
  • 5 ASA
  • Immune suppressants
    • Azathioprine
    • Methotreaxate
  • Biologic therapy
  • Others –diet, FMT, antibiotics, probiotics, novel agents
37
Q

what are the modes of delivery of steroids?

A

IV, orally, rectal enemas

38
Q

how do steroids work in IBD?

A
  • Diffuse and bind in nucleus to Glucocorticoid Responsive Elements (GRE).
    • GRE interact with specific DNA sequences
    • Increase anti-inflammatory gene products
    • Block pro-inflammatory genes `
39
Q

what is the use of steroids in IBD?

A

short term

as a bridge to other therapy/interventions

in acutely unwell patients

40
Q

what are the side effects of steroids?

A
41
Q

what is the effect of 5 ASA?

A
  • Inhibition of pro-inflammatory cytokines (IL-1 and TNF-a )
  • Inhibition of the lipo-oxygenase pathway i.e. prostaglandin and leukotrienes
  • Scavenging of free radicals
  • Inhibition of NF-kB/ TLR via PPAR-gamma induction (peroxisome proliferator activated receptor-gamma)
  • Some immunosuppressive activity – inhibiting T cell proliferation, activation and differentiation
  • Impairs neutrophil chemotaxis and activation
42
Q

what is the mode of delivery of 5 ASA?

A

orally or rectally

43
Q

what are the side effects of 5 ASA?

A
  • Intolerance
  • Diarrhoea
  • Renal impairment
  • Headache
  • Malaise
  • Pancreatitis
  • Pneumonitis
44
Q

how does azathioprine work?

A
  • 6-TG (the active metabolite) interferes with adenine and guanine ribonucleotide production.
  • Results in reduced number of B and T lymphocytes, immunoglobulins and interleukins.
  • Another pathway potentially results in apoptosis of T cells
45
Q

what needs to be checked before giving asathioprine?

A
  • Thiopurine Methyltransferase (TPMT) (low in patients on this medication)
  • Hep B/C
  • HIV
  • Chicken pox
  • Vaccinations
  • TB
  • Frequent bloods on starting
  • Maintenance bloods
46
Q

how does methotrexate work?

A
  • Interferes with DNA synthesis & cell reproduction
  • Increased adenosine levels (anti-inflammatory)
  • Increased apoptosis of peripheral T cells
47
Q

what happens when taking methotrexate?

A
  • Takes 3 months to work
  • Need history re liver abnormalities
  • Monitor LFTs, FBC
  • Advise NO pregnancy
  • Folic acid supplements (reduces side effects)
  • WEEKLY DOSE
48
Q

what are the side effects of methotrexate?

A
  • Rash
  • Nausea, mucositis, Diarrohea
  • Bone marrow suppression
  • Hypersensitivity pneumonitis
  • ↑’ed liver enzymes
  • Hepatic fibrosis/cirrhosis
  • Known abortifacient
  • No documented ↑ed risk of lymphoma or skin cancer
49
Q

what are the types of biologics that can be used?

A
  • Anti-TNFα – infliximab, adalimumab
  • Anti- α4β7 Vedolizumab
  • Anti-IL12/IL23 Ustekinumab
50
Q

what are the effects of TNF alpha?

A
51
Q

how is infliximab delivered?

A

IV

in hospital-less frequent

induction 0,2,6 weeks

maintenance 8 weekly

52
Q

how is adalimumab delivered?

A

S/C

160/80/40mg Every other week

at home -more frequent

53
Q

how is golimumab delivered?

A

S/C

54
Q

what are the side effects of biologics?

A
  • Opportunistic infections
  • Infusion or site reactions
  • Infusion reactions
  • Neutropenia
  • Infections
  • Demyelinating disease
  • Heart failure (HF)
  • Cutaneous reactions, including psoriasis
  • Malignancy
  • Induction of autoimmunity
55
Q

how is IBD managed?

A

combination therapy

  • AZA/ 6MP and aTNF act synergistically
  • Combination is superior in inducing and maintaining response and remission
  • Reduces the rate of antibody formation

other mediations

  • Cilosporin
  • Vedolizumab (anti-integrin)
  • Ustekinemab (anti IL12/23)
56
Q

what are other consideration treatments in IBD?

A
  • Dietary therapy
    • Liquid therapy diet
    • Increased use in children
    • As effective as steroids
    • Use in small bowel Crohns disease
    • Weeks
  • Antibiotics
    • No hard evidence
    • Good for sepsis
  • Faecal Microbiota Transplantation (FMT)
    • Lots research into the role of the microbiome
  • Novel agents

1B Gastroenterology (12 decks)

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