W3 GI Flashcards
1
Q
other name for jaundice and what is it
A
icterus
yellowing of sclera and skin due to increased levels of bilirubin in the blood
2
Q
Branches of bile duct and what it drains into
A
branches of bile duct= cystic duct and common hepatic duct
bile duct drains into 2nd part of the duodenum
3
Q
What drains into the 2nd part of the duodenum
A
the bile duct and the pancreatic duct
4
Q
how does bile move from liver to gall bladder
A
bile moves down common hepatic duct, up the cystic duct into gall bladder
5
Q
Journey of bile duct to reach the duodenum
A
Bile duct descends posterior to 1st part of duodenum to connect with the main pancreatic duct forming the ampulla of vater/ hepatopancreatic ampulla which drains into the 2nd part of the duodenum through the major duodenal papilla
6
Q
Name the sphincters where the bile duct and pancreatic duct connect with the duodenum
A
Bile duct sphincter
pancreatic duct sphincter
Sphincter of Oddi
7
Q
What is endoscopic retrograde cholangiopancreatography used to do
A
view the biliary tree and pancreas
8
Q
Extra-hepatic causes of jaundice
A
Obstruction of the biliary tree by gallstone or carcinoma at the head of the pancreas
causes backflow of bile to the liver and bile overspills into the blood
9
Q
Anatomical parts of the pancreas
A
Head and uncinate
neck
body
tail
10
Q
Nerve supply of the pancreas
A
Vagus nerve (P) Abdominopelvic splanchnic nerves (S) both form a plexus around the celiac trunk
superior mesenteric ganglia hitch a ride with the arteries to get to the pancreas
11
Q
What influences pancreatic secretion
A
hormones from duodenum epithelium and proximal intestinal epithelium which is stimulated by stomach acid
12
Q
Arterial blood supply of the pancreas
A
Splenic artery gives rise to pancreatic arteries
anterior and posterior superior pancreaticoduodenal artery arises from the gastroduodenal artery
anterior and posterior inferior pancreaticoduodenal artery arises from the superior mesenteric artery
13
Q
Describe a cause of pancreatitis
A
Blockage of ampulla by gall stone
Bile can’t get into duodenum - backs up into pancreas - irritation and inflammation of pancreas
14
Q
Describe pain due to pancreatitis
A
Pancreas is a foregut and midgut organ so could cause epigastric and/or umbilical pain
can also radiate to the back
15
Q
How is SI split into foregut and mid gut
A
foregut- 1st and 2nd part of duodenum=foregut
the rest of SI=midgut
16
Q
Four parts of duodenum, where it begins, and what it secretes into blood
A
superior, descending, horizontal and ascending
begins at the pyloric sphincter
peptide hormones
17
Q
Where would pain from a duodenal ulcer present
A
epigastric
18
Q
Effect of Autonomic innervation of the duodenum
A
P- relaxation
S-contraction
19
Q
Blood supply of the Duodenum
A
Branches of anterior and posterior superior pancreatoduodenal artery supply proximal duodenum (1st and 2nd part of duodenum)
Branches of the inferior pancreatoduodenal artery supply horizontal and ascending duodenum (3rd and 4th parts)
This is embryological and marks division between foregut and midgut
superior pancreatoduodenal artery arises from the gastroduodenal artery
inferior pancreatoduodenal artery arises from the splenic artery
20
Q
where does the jejunum begin
A
duodenaljejunal flexure
21
Q
where does the ilium end
A
ileocecal junction
22
Q
Differences in jejunum and ilium
A
jejunum mucosa has plicae circulares whereas the ileal mucosa is much smoother
Jejunum is quite wide, distal ileum is quite narrow
Proximal jejunum is very highly folded
PC increase SA
PC more sparse at ileum than jejunum
23
Q
Arterial blood supply of jejunum and ileum
A
superior mesenteric artery via jejunal and ileal arteries
24
Q
Venous drainage of jejunum and ileum
A
jejunal and ileal veins to the superior mesenteric veins to hepatic portal vein
25
Where does the superior mesenteric artery arise from
SMA is the 2nd of the midline branches of the abdominal aorta
26
what are the jejunal and ileal arteries and veins in
within the mesentary
27
- what do jejunal and ileal arteries give rise to
| - describe the difference in the ileal and jejunal arteries
Loop and join to form arterial arcades which then give rise to straight arteries (vasarecta) that go to walls of jejunum and ileum
Jejunum has less arcades and longer recta, ileum has more arcades and shorter vasarecta
28
how contents of SI reach liver
Venous drainage absorbs proteins and carbohydrates from SI back into portal venous system to go back to the liver by jejunal and ileal veins which feed back into superior mesenteric vein to the hepatic portal vein to the liver
29
Describe absorption of fats
Bile helps absorption of fat into intestinal cells and then go into lacteal cells of intestinal cells
travel in lymphatic system to the left venous angle
30
where do celiac nodes drain
foregut organs
31
where do superior mesenteric nodes drain
midgut organs
32
where do inferior mesenteric nodes drain
hindgut organs
33
where do lumbar nodes drain
kidneys, posterior abdomen wall, pelvis and lower limbs
34
where do superficial lymph vessels drain to
Deep lymph vessels
35
Two places that lymph will ultimately drain to
```
Thoracic duct (3/4)
Right lymphatic duct (1/4)
```
to the venous angles i.e. junctions between the subclavian veins and internal jugular vein
36
Risk factors of oral cancer
Smoking, alcohol, diet, tobacco chewing, HPV, UVL, previous oral cancer, Candida, Syphilis drugs
37
Recommended Upper weekly limit of alcohol intake for men
14 units
| 2 units per day
38
What is binge drinking
At least 8 units for men and at least 6 units for women
39
How does alcohol cause oral cancer
Ethanol is converted to acetaldehyde by ADH
Acetaldehyde is a carcinogen
acetaldehyde is converted into acetate (harmless) by ALDH
ADH is found in the mouth, ALDH isnt
40
Dietary components which increase risk of Oral Cancer
Low in vitamin A and C and Iron
41
Why may oral sex have link to oral cancer
HPV 16 and 18
| association with oropharyngeal cancer
42
Presentation of oral cancer
```
Red patches
White patches
Red/White patches (erythroleukoplakia)
Ulceration
Bleeding
Induration (hard feeling)
Exophtosis
Lymphadenopathy
```
43
What type of cancer does oral cancer tend to be
Invasive squamous cell carcinoma
44
High risk sites of oral cancer
- Soft, non-keratinising sites eg ventral tongue, floor of mouth
- Lateral tongue
rarer sites= dorsal tongue and hard palate
45
read only
| potentially malignant lesions
erythroplakia- Red patch
Erythroleukoplakia-Red-white patch
Leukoplakia-White patch
Erosive lichen planus
submucous fibrosis- mucous fibrosis, associated with bidy chewing
Dyskeratosis Congenita- Rare syndrome of white patch in the mouth, increased skin pigmentation and nail dystrophy
46
Signs of oral cancer
```
Red/White/Red-white lesions
Ulcer
Numbness of lips or face
unexplained pain in mouth or neck
change in voice
dysphagia
Drooping eyelid or facial palsy (tumour in parotid gland through facial nerve)
Fracture of mandible (osteosarcoma)
Double vision- tumour has disturbed position of globe of the eye
Blocked or bleeding from nose
Facial swelling
```
47
Four questions you should ask patient with ulcer on tongue
How long have had it? (normal would heal in 7-10 days)
Painful?
Smoke/drink?
Colour? (red or red/white are more dangerous)
48
in what part of the mediastinum is the oesophagus located
in the posterior mediastinum
49
Type of epithelium in oesophagus
squamous stratified epithelium
50
Describe the two inflammatory disorders of the oesophagus and their causes
acute oesophagitis: rare
corrosion following chemical ingestion, infective in immunocompromised patients
can be caused by candidiasis, herpes, CMV
chronic oesophagitis: common
reflux disease, crohn's disease
51
Reflux Oesophagitis-what is it, causes, pathology
inflammation of the oesophagus due to reflux of low pH gastric contents
may be due to defective sphincter, hiatus hernia
abnormal oesophageal activity and increased intra-abdominal pressure (pregnancy)
52
Microscopic appearance of reflux oesophagitis
basal zone epithelial hyperplasia, elongated papillae
intra-epithelial neutrophils, lymphocytes, eosinophils
increased cell proliferation to compromise for increased cell desquamation
53
Complications of Reflux
Ulceration and bleeding
Stricture (narrowing)
Barrets oesophagus
54
What is Barrets oesophagus
type of metaplasia- replacement of stratified squamous epithelium by columnar epithelium due to acid reflux or bile
protective response, faster regeneration
red, velvety mucosa
55
why is barretts oesophagus dangerous
pre-malignant, unstable mucosa
increased risk of dysplasia and carcinoma of oesophagus
56
```
What is allergic oesophagitis
History
investigations
who is likely to get it
appearance
```
Rare form of oesophagus inflammation
```
Eosinophilic inflammation (increased Eos blood)
history of allergy, asthma
young, more males than females
pH probe - for reflux
ridged, spotty oesophagus
```
57
Treatment of allergic oesophagitis
Steroids, Montelukast, Cromoglicate
58
Benign tumours of the oesophagus
Squamous papilloma (rare, HPV related)
leiomyomas, lipomas
fibrovascular polyps
granular cell tumours
59
Two types of malignant oesophageal tumours and who do they occur in
- Squamous cell carcinoma (more common in males, S. Africa, Brazil, central china)
- Adenocarcinoma (more common in Caucasians, in males and obese, most common in lower 1/3 oesophagus)
60
Causes of squamous cell carcinoma
```
Vitamin A or Zinc deficiency
Tannic acid/strong tea
smoking, alcohol
HPV
Oesophagitis
Genetic
```
61
main risk factor of adenocarcinoma
Barrets oesophagus
62
Stepwise progression of adenocarcinoma of oesophagus
```
chronic reflux oesophagitis
barrets oesophagus (metaplasia)
low grade dysplasia
high grade dysplasia
adenocarcinoma
```
63
Presenting symptoms of oesophageal carcinoma
dysphagia due to obstruction (local)
| metastases
Anaemia
weight loss
loss of energy
64
mechanisms of oesophageal carcinoma metastases
Direct invasion
Lymphatic
Vascular
65
why may oesophagus tear
prolonged vomiting
66
effect of liver cirrhosis on oesophagus
oesophageal varices
67
what is the most commo type of oral cancer
| presentation
Squamous cell carcinoma (90%)
| white, red, ulcers
68
High risk areas of mouth for oral cancer
```
Soft palate
floor of mouth
lateral and ventral tongue
retromolar pad
tonsils
```
69
Rare sites of oral cancer
dorsum of tongue, hard palate
70
Pathology of oral cancer
Malignant squamous epithelium
| invasion and destruction of local tissues
71
Variation in grades of SSC
well differentiated- obviously squamous, prickles and keratinisation
poor differentiation- difficult to identify
72
Acute gastritis cause
chemical injury
73
Chronic gastritis causes
autoimmune (rarest)
bacterial (H pylori)
chemical
74
Antibodies involved in Autoimmune Chronic Gastritis
Type of disease
complications
anti-parietal and anti-intrinsic factor antibodies
multi-system disease (gastric, bone marrow, spinal cord)
atrophy and intestinal metaplasia in stomach body-increased risk of malignancy
pernicious anaemia, macrocytic due to Vitamin B12 deficiency -SACDC
75
SACDC
Subacute combined degeneration of spinal cord= degeneration of the posterior and lateral columns of the spinal cord as a result of vitamin B₁₂ deficiency, vitamin E deficiency, and copper deficiency. It is usually associated with pernicious anaemia.
76
H pylori associated with Chronic gastritis
| where it inhabits, appearance, what is produced against it
Bacteria inhabits between epithelium and mucus barrier
G- curvilinear rod
early acute inflammatory response- if not cleared will turn into chronic inflammatory response
IL8 released in response to H pylori infection
77
why is H pylori dangerous
Lamina propria produces antibodies against H pylori
| increases risk of duodenal and gastric ulcer and of Gastric carcinoma or lymphoma
78
Causes of Chemical gastritis
due to NSAID, alcohol, bile reflux
direct injury to mucus layer by fat solvents
epithelial regeneration, hyperplasia, congestion and inflammation
produces erosion and ulcers
79
what is peptic ulceration and its casue
Breach in GI mucosa due to acid or pepsin attack
80
Sites of chronic peptic ulcers
1st part of duodenum
stomach (body and antrum junction)
oesophago-gastric junction
81
Causes of Chronic peptic ulcers
Synergism
- Failure of mucosal defence
- Increased acid production
causes gastric metaplasia then H pylori infection, inflammation and epithelial damage and ulceration
82
Macroscopic Appearance of peptic ulcers
2-3cm
| characteristic clear cut edges, punched out
83
Microscopic appearance of peptic ulcers
layered appearance
floor of necrotic fibrinopurulent debris
base of inflammed granulomatous tissue
deepest layer is fibrotic scar tissue
84
Complications of peptic ulcers
perforation, penetration, haemorrhage, stenosis, pain
85
what are polyps
benign tumours
86
three types of malignant gastric tumours
carcinomas
lymphomas
GI stromal tumours
87
Role of H Pylori in Gastric Adenocarcinoma
anti-H Pylori antibodies give higher risk of cancer
H. Pylori causes chronic gastritis, causing intestinal metaplasia/atrophy-dysplasia-carcinoma
88
Diseases which contribute to gastric cancer
```
H pylori
Pernicious anaemia
Partial gastrectomy
Lynch syndrome
Menetriers Disease
```
89
Two types of gastric adenocarcinoma
| which has a poorer prognosis
Intestinal type-exophytic/polypoid mass (volcano)
| Diffuse type-expands/infiltrates stomach wall (poorer prognosis)
90
Spread of gastric adenocarcinoma
locally to other organs
lymph nodes (omental)
haematogenous (liver ect)
transcoelomic (into peritoneal cavities and ovaries, (Kruckenburg)
91
Gastric lymphoma
Solid mucus associated lymphoid tumours
associated with H Pylori
Continuous inflammation- B cell proliferation- low grade lymphoma-high grade lymphoma
92
Histological appearance of Gastric lymphoma
sheets of lymphoid cells which attach to epithelial gastric pits
93
what does GI stromal tumour produce, mutation involved
produce spindle cell masses driven by mutations in KIT oncogene
94
what are the haematinic deficiencies
Vitamin B12, Folate, Iron
95
what is angular cheilitis and its causes
cracking at the corners of the mouth
Causes: candida infection, with or without bacteria, usually Staph Aureus
inflammation of upper muscoa-is present it may be denture stomatitis (type of candida infection)
recurring condition- underlying anaemia or haematinic deficiency
(If swab of skin doesnt show Staph Aureus or underlying pathology or full serum count, serum B12 folate ect is normal- consider deficiency)
can be caused by anaemia or hematinic deficiencies
96
what can recurrent oral ulcers be a sign of
celiac disease (caused by anaemia or folate deficiency)
97
Describe recurrent aphthous like stomatitis minor and major and their potential causes
minor- halo, yellow centre, up to 10, 1-2 weeks to heal
major-larger, up to 3, 4 weeks to heal, scarring
anaemia/haematinic deficiencies
98
recurrent aphthous like stomatitis- herpetiform
Small ulcers, sometime coelesce to form larger ulcers, painful
Numerous, up to 100
7-14 days to heal
99
underlying causes of anaemia and haematinic deficiencies
Gi bleeding
| Malabsorption
100
Describe two types of IBD
Crohns Disease-can affect anywhere in GI tract, blood loss, malabsorption
Ulcerative colonitis-blood loss
101
Crohns disease and its facial features
Affects anywhere from mouth to anus
chronic granulomatous condition
orofacial granulomatosis:
oral ulceration, mucous tags, cobblestone mucosa, swollen lips, angular cheilitis, gingival erythema
102
Mouth disease that affects type II diabetes
Thrush- acute pseudomembranous candidosis
103
What medications cause dry mouth
PPI
Anti-muscarinics
Tricyclic antidepressants
opioid analgesia
104
what medications cause angioedema
ACE inhibitors
105
Causes Osteonecrosis of the jaw
Bisphosphonates for osteoporosis
| metastases
106
what medications cause oral ulceration
methotrexate used in rheumatoid arthritis
| Nicorandil (ulceration of other parts of GI tract, fistula)
107
Lichen planus- where does it present and type of reaction?
affects oral mucosa, oesophagus, skin, genitals ect
Oral Lichen lesions can be a type IV hypersensitivity reaction to dental restorative materials and mercury in restoration
presents in mouth and on skin
108
name of lichen planus skin lesions
violaceous papules (itchy)
109
mucus membrane pemphigoid- type of reaction and symptoms
Oral, nasal, genital mucosa, conjunctiva
Autoimmune condition - antibodies target BM of epithelium so epithelium separates from underlying connective tissue producing vesicles (small blister) and bullae (blister)
Scarring in eye can lead to blindness
Gingivae eyrthema
Red eye
Superficial ulceration of buccal mucosa
110
Sjogrens and its symptoms
Autoimmune condition- dry mouth/eyes due to damage to exocrine glands
(Rheumatology-Type of connective tissue disease)
111
Oral manifestations of HIV/AIDS
Candidosis
Hairy leukoplakia (white patch, lateral tongue)
Herpes simplex virus infection
Kaposi's Sarcoma (malignant)
112
Trigeminal neuralgia
sharp, 'electric shock' short lived burst of pain of less than 2 minutes of areas innervated by trigeminal nerve and its branches
recurrent
Usually unilateral, mostly areas innervated by maxillary and mandibular division
Lots of secondary causes eg tumour pressing nerve, MS
113
investigation for trigeminal neuralgia
MRI
MRI will show vascular loop in close proximity to trigeminal nerve in posterior cranial fossa, pressure from which results in morphological changes affecting the nerve
114
Treatment for trigeminal neuralgia
Treatment= carbamazepine/gabapentin (anti-epileptic)
115
what is apthous ulceration a sign of
Vit B12, folate and iron deficiency
116
Cause of angular cheilitis
iron deficiency
117
cause of swollen tongue
iron deficiency
118
Oral manifestations of crohns disease
Orofacial granulomatosis (non-caseating)
```
oral ulceration
mucosal tags
angular chelitis
cobblestone mucosa (raised areas)
swollen lips
gingival erythema
```
119
what is Pseudo-membrane candidosis and in what condition do you get it?
Thrush
| Type II diabetes
120
First line treatment for squamous cell carcinoma of the upper oesophagus
Radiotherapy and chemotherapy
121
What is dyspepsia
indigestion
| upper abdominal pain, often after eating drinking
122
what is peptic ulcer disease
break in mucosa in stomach, duodenum or lower oesophagus
123
Criteria of dyspepsia
epigastric pain/burning, postprandial fullness, early satiety
124
where does dyspepsia come from
foregut organs
125
Causes of dyspepsia
Organic (25%)
Peptic ulcer disease, drugs (NSAIDs), gastric cancer
Functional (75%)
Idiopathic, no evidence of structural disease but associated with functional gut disorders like IBS
126
Examination results in uncomplicated dyspepsia
Epigastric tenderness only
127
Examination result of complicated dyspepsia
Cachexia, mass, evidence of gastric outflow obstruction, peritonism
128
Steps in Dyspepsia management
1. Treat if reflux, check that it isnt from liver, heart, GB, Pancreas, NSAID
2. Check for alarm features
3. Consider lifestyle, Antacids/ H2RA
4. Hp test
if + treat, if - and less than 55 treat as functional dyspepsia, if more than 55 consider hospital
129
Presentation of peptic ulcer disease
Pain in epigastric region, radiates to back
| also nocturnal, relapsing and remitting
130
Causes of peptic ulcer disease
H pylori, NSAID, gastric motility/obstruction
131
Microbiology of H pylori
G- flagellate, microaerophilic bacilli
132
Transmission of H pylori
oral-oral and faecal-oral route
acquired in infancy, can cause issues later in life
133
Consequences of H pylori
1. nothing (majority)
2. peptic ulcers
3. gastric cancer (non-cardia adenocarcinoma)
134
Draw the negative feedback loop of gastrin production in the stomach
acid in the stomach inhibits the release of gastrin by G cells, gastrin release will initiate parietal cells to release HCl
135
Investigations of H pylori
Gastric biopsy
urease test
histology, culture/sensitivity
Faecal antigen test
136
How does H pylori increase the pH of its environment
H pylori uses urease to break urea down into ammonium and bicarbonate
137
Treatment of Peptic ulcer disease
ALL get PPI and test for H pylori
Treat cause: stop NSAIDs, lifestyle measures, treat any H pylori (if H pylori -, antacids)
138
Anti-secretory therapy for Peptic ulcer disease
Omeprazole 20mg/day= PPI (better)
| Ranitidine 300mg/day= H2RA
139
Treatment of H pylori
PPI+ amoxicillin 1g bd+ clarythromycin 500mg bd
PPI+ metronidazole 400mg bd+ clarithromycin 250mg bd
140
Complications of Peptic ulcer disease
anaemia/bleeding, perforation, scarring
141
presentation of appendicitis
Right iliac fossa pain
142
presentation of appendicitis
- Begins with central colicky pain that then shifts to the right iliac fossa
- sore on coughing and laughing, guarding, rebound
- loss of appetite, may vomit, may not have opened bowels that day due to inflammation
- look flushed (rosy red cheeks), mild tachycardia, mild pyrexia (never over 39 degrees, 37.8-37.9 degrees),
143
what is mcburneys point
near the most common location of the appendix
Point over the right side of the abdomen that is one-third of the distance from the anterior superior iliac spine to the umbilicus
144
who gets appendicitis
children and young adults, another peak in the early
in adult 40-60 presents with appendicitis like pain, CT scan for tumour
145
who gets appendicitis
children and young adults, another peak in the early
in adult 40-60 presents with appendicitis like pain, CT scan for tumour
3:2 male to female until age of 25, then equal
146
what happens inside appendix in appendicitis?
lumen may or may not be occluded
mucosal inflammation
lymphoid hyperplasia
mucus, exudate
147
Rosvings sign
Sign of appendicitis where pushing down on the left side causes pain or the right side
148
psoas sign
sign of appendicitis where the patient flexes their right hip to lift inflamed appendix off the psoas
149
Obturator sign
sign of appendicitis where flexing the right hip and internal rotation causes pain (appendix touches obturator internus)
150
*Investigations of appendicitis
Ultrasound
Bloods- CRP, WCC
Urinalysis
AXR to exclude other causes
151
Score used for appendicitis
Alvarado score
```
Migration of pain to RLQ
Anorexia
Nausea and vomiting
Tenderness of RLQ
Rebound pain
Elevated temperature
Leukocytosis
Shift on WBC to left
Sore to move/laugh/cough
Flushed red face
Foetor oris (bad breath due to rotting appendix)
```
152
Management of appendicitis
```
Antipyretics
Analgesia
Theatre
Antibiotics
Appendicectomy
```
153
Treatment of appendix mass
antibiotics
| theatre if it gets more complicated
154
Treatment of appendix abscess
Radiological drain
155
Causes of small bowel obstruction and what happens
lumen-gall stone, food, bezoar
wall-tumour, crohns, radiation
outside wall-adhesions, hernia
colicky central pain, absolute constipation, vomiting, burping, abdominal distension, vomiting stool, boborygmi
156
Investigations of small bowel obstruction
Urinalysis, bloods, gases
| AXR, contrast CT of abdomen, gastrograffin studies
157
Treatment of small bowel obstruction
'Drip and Suck'
ABC, Analgesia
IV fluid with potassium (hypokalaemia, alkalosis)
Catheterise, NG tube (Ryles tube)
Antithromboembolic measures
only drip and suck adhesional bowel obstructions
158
What is malabsorption
defective mucosal absorption
159
Causes of malabsorption
Defective luminal digestion, mucosal disease, structural disorders
160
Causes of malabsorption and examples
Defective luminal digestion, mucosal disease, structural disorders
Celiac disease, Crohns disease, post-infection, biliary obstruction, cirrhosis, pancreatic cancer...
161
Digestive and absorptive causes of protein malabsorption
digestive-gastrectomy (poor mixing), exocrine pancreatic deficiency, trypsinogen deficiency, congenital
absorptive-celiac disease, short bowel syndrome ect
162
causes of fat malabsorption
digestive: issues with lipolysis (pancreas) or bile salts (liver)
absorptive: issues in jejunal mucosa
post-absorptive: issues with lacteal delivery
163
Causes of carbohydrate malabsorption
digestive: pancreatic a-amylase deficiency
absorptive: Celiac disease, Crohns disease...
164
Coeliac Disease
- cause
- pathology
- symptoms
- diagnosis
- treatment
- exposure to wheat, barley, rye will cause lesions on mucosa
- individuals with antigen presenting cells expressing HLA-DQ2 or HLA-DQ8, bind to dietary gluten peptides and activate mucosal T lymphocytes, cytokines cause mucosal damage
- can be asymptomatic, diarrhoea, weight loss, abdominal discomfort
- IgA anti-tissue transglutaminase biopsy
- Gluten free diet
165
What is lactose malabsorption caused by?
Deficiency of lactase
166
What is lactose malabsorption caused by?
| symptoms of lactose malabsorption
- Deficiency of lactase
| - Diarrhoea, abdominal discomfort, excess flatulence following ingestion of dairy products
167
What is lactose malabsorption caused by?
symptoms of lactose malabsorption
How to diagnose lactose malabsorption
- Deficiency of lactase
- Diarrhoea, abdominal discomfort, excess flatulence following ingestion of dairy products
- lactose breath hydrogen test or oral lactose intolerance test
168
What is lactose malabsorption caused by?
symptoms of lactose malabsorption
How to diagnose lactose malabsorption
Treatment of lactose malabsorption
- Deficiency of lactase
- Diarrhoea, abdominal discomfort, excess flatulence following ingestion of dairy products
- lactose breath hydrogen test or oral lactose intolerance test
- lactose free diet
169
- What is tropical sprue
- Symptoms of tropical sprue
- Treatment of tropical sprue
Colonisation of intestine by infectious agents or alterations in gut flora by exposure to another env agent
- diarrhoea, steatorrhea, nausea, anorexia, weight loss, anaemia
- Tetracycline and folic acid
170
Name of pathogen and Antigen involved in whipples disease
Tropheryma whipple
| HLA-B27
171
Name of pathogen and Antigen involved in whipples disease
Tropheryma whipplei
| HLA-B27
172
How to diagnose whipples disease
micorscopy showing tropheryma whipplei in tissues
173
How to diagnose whipples disease
microscopy showing tropheryma whipplei in tissues
174
Treatment of whipples diease
anti-microbials
175
Symptoms of crohns disease
mostly RLQ discomfort and abdominal pain, diarrhoea, fever, weight loss
176
Diagnosis of crohns disease
endoscopy, barium swallow, CT, MRI
177
Treatment of crohns disease
Steroids, immunosuppressants, azathioprine 6-MP, anti-TNF
178
What is Giardia lamblia and how it it transmitted
parasitic infection, contaminated water
179
Symptoms of Giardia lamblia infection and diagnosis
Diarrhoea, flatulence, abdominal cramps, epigastric pain, nausea
1/3 vomiting
diagnosed by stool sample
180
Treatment of Giardia lamblia
metronidazole, 1 week
181
small bowel bacterial overgrowth
a) causitive organisms
b) signs
c) what does the disease cause
d) diagnosis
e) what test will diagnosis bacterial overgrowth
f) Treatment
a- E. Coli, Bacteroides
b- diarrhoea, steatorrhea, macrocytic anaemia
c- fistulas, diverticula, strictures related to crohns disease
d- low cobalamin, high folate levels
e-Schilling test
f- surgical correction of abdominal blind loop, tetracyclines for 2-3 weeks
182
Important aspects of GI history
GI symptoms, Travel history, PMH, Dietary history, Drugs history, Social history (alcohol, water supply)
change in bowel habits, eg pale colour, steatorrhea
183
In what disease states should malabsorption be suspected?
diseases of the liver, pancreas and small bowel
184
Questions to ask about relating to diarrhoea
Duration, fat globules, floating/hard to flush away, offensive
185
Causes of easy bruising
Vitamin K deficiency
186
Cause of scurvy
Vitamin C deficiency
187
what is acrodermatitis enteropathica caused by? treatment? how it is acquired? symptoms?
autosomal recessive
impaired zinc uptake so treatment= zinc supplements
rash, perioral, acral, alopecia
188
Cause of Dermatitis herpetiformis
| what disease may it indicate
Sub-epithelial deposition of IgA at extensor surface causing itchy blisters
may indicate coeliac disease
189
Cause of glossitis and angular stomatitis
Vitamin B and iron deficiency
190
Cause of spooning of nails
Iron deficiency (thyroid)
191
Tests in suspected malabsorption
FBC, coagulation, LFTs, albumin, Ca/Mg, stool culture
| endoscopy, histology, X ray, CT
192
Three causes of Gastro-oesophageal reflux disease
1. incompetent LOS
2. poor oesophageal clearance
3. barrier function/visceral sensitivity
193
Symptoms of GORD
Heartburn, Acid reflux, chest pain
waterbrash (acid taste)
weight loss, coughing
dysphagia, odynophagia, hoarseness
194
Investigations of GORD
Endoscopy
Barium swallow
oesophageal manometry (LOS function)
pH studies
195
Alarm symptoms in dyspepsia
should prioritise patients with these signs as they may have oesophageal carcinoma
Hx cancer, anaemia, pernicious anaemia, PUD >20 years, dysphagia, weight loss, vomiting,
196
what is the Z line
normal marking between the oesophagus and stomach
197
How do we grade oesophagitis
Severity of errosive disease
198
Complications of GORD
Oesophagitis, schatzki ring causing sticturing, metaplastic change
199
Which oes cancer is associated with barretts oes?
Adenocarcinoma
normal>oesophagitis>barrets>adenocarcinoma
200
3 lifestyle modifications for GORD
smoking cessation
lose weight
prop up bed head
201
Can antacids heal/prevent GORD?
no- will neutralise acid, but wont heal/prevent
202
Name two H2RA
Why do HR2A have a worse outcome than the placebo in GORD
Ranitidine, Cimetidine
Block H2RA so body increases gastrin and ACh production to maintain acid output- sometimes patient will forget to take H2RA- rebound acid production
203
First line treatment of GORD
PPI
204
Nissen fundoplication and who it is used in
tighten LOS by wrapping the fundus around it
| used in young people who want to come off PPI
205
Grading Barrets oesophagus
| Management of BO/Dysplasia
irreversible Intestinal metaplasia
Graded as low/high
3 month surveillance, optimise therapy to 40mg x2
remove by endoscopic resection (EMR) and ablate rest of BO with HALO technique
206
What is a hiatus hernia
part of stomach pushes up into the thorax through a weakness in the diaphragm
207
Gastroparesis
poor emptying of stomach without physical blockage in pylora, when vagus nerve is damaged and pyloric sphincter closes
208
Symptoms of gastroparesis
Bloating, loss of appetite, nausea, vomiting, weight loss, upper abdominal pain
209
Causes of gastroparesis
Think nerve damage
| Cannabis, idiopathic, diabetes, medications (opioids, anti-cholinergics), systemic disease
210
Investigations of gastroparesis
- Gastroscopy (ensure no obstruction or malignancy or pylorus/antrum)
- gastric emptying study (isotope consumed, calculate t1/2 of emptying)
211
Management of gastroparesis
Gastric pacemaking (particularly useful for diabetes)
liquid/sloppy diet, eat little and often, promotility agents
remove cause eg drugs
212
Hallmark of achalasia
Oesophageal beaking
213
What is achalasia
The LOS cant relax, so oesophagus will have reduced peristalsis and become dilated
214
1st line investigation of achalasia and other
1st line= oesophageal manometry
also endoscopy, barium swallow (shows beaking)
215
Treatment of achalasia
balloon dilation, cardia myotomy, botox (older patients), oesophagectomy (end stage)
216
what GI diseases is weight loss a sign of?
colorectal cancer, gastric cancer, oesophageal cancer crohns disease, celiac disease
impaired GI motility, intra-abdominal infection, acute liver disease
217
How to identify malnutrition
MUST score (malnutrition Universal screening tool)
1. Calculate BMI
2. % unplanned weight loss
3. acute disease effect (no intake >5 days)
4. Calculate overall risk of malnutrition from 1,2,3
5. Use guidelines and local policy to make a plan
0: Routine care
1: Observe
2+: Treat
218
What is Anthropometry
nutritional assessment- mid arm muscle circumference, triceps, grip strength
219
Usefulness of Albumin in nutritional assessment
50% protein in plasma, non-specific marker of illness
220
Usefulness of Transferrin in nutritional assessment
synthesis reduced in protein reduction- affected by APR, anaemia, liver disease
221
Usefulness of Urinary creatine in nutritional assessment
assessment of renal function
222
Transthyretin
recent dietary intake- increased in ureamia and dehydration, decreased by fasting and APR
223
Retinol binding protein
effected by energy
increased by increased GFR and alcoholism
decreased by chronic liver disorders, vitamin A and zinc deficiency
224
IGF1
reduced in acute and chronic malnutrition, liver disease and renal failure
225
Order of nutritional support
1. food first
2. oral nutritional support (snacks, sip feeds)
3. Enteral tube feeding
4. Parental tube feeding (IV)
226
who needs nutritional support
BMI <18.5
Unintentional weight loss >10%
BMI <20 and unintentional weight loss of >5%
having eaten nothing for >5days
poor absorptive capacity, nutritional loses, , increased nutitional needs
227
Enteral Tube feeding
Delivery of nutritionally complete feed via tube into stomach, duodenum or stomach
nasogastric, nasoduodenal, nasojejunal tube
percutaneous endoscopic gastrostomy
percutaneous jejunostomy
surgical jejunostomy
228
Indications for EFT
Inadequate or unsafe oral intake but a functional accessible GI tract
eg unconscious, NM swallowing disorder, upper GI obstruction
229
Contra-indications of EFT
```
Lower GI obstruction
Prolonged intestinal ileus
severe diarrhoea/vomiting
high enterocutaneous fistula
intestinal ischaemia
```
230
What is parental feeding
admin of nutrition via central or peripheral vein
last resort
231
What is Refeeding syndrome and its metabolic consequences
When someone is rapidly refed after a period of under nutrition
refeeding leads to increased insulin- increased uptake of Glucose, thiamine, K+, Mg2+, PO4
hypokalaemia, hypomagnesaemia, hypophosphataemia, thiamine deficiency, salt and H2O retention, oedema
232
when is refeeding syndrome more likely to occur?
feeding PN or EN
| oral feeding, less likely
233
Physiological consequences of refeeding syndrome
seizure, arrhythmia, altered level of consciousness, respiratory failure, cardiovascular collapse, death
234
moderate risk of refeeding syn
little/no nutrition for >5 days
235
extremely high risk of refeeding syn
BMI <14, no intake >15 days
236
Tumour associated with lump at left supraclavicular fossa
Gastric adenomacarcinoma
