Phase 2

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Gastrointestinal 1

• Phase 2
• Hannah Ojidu

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Whats covered

• Common causes of abdominal pain
• GORD
• Peptic Ulcer disease
• Inflammatory Bowel Disease
• Gastroenteritis
• Coeliac disease

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Whats not covered

• GI bleeding
• GI malignancy
• Biliary tract disorders cholecystitis, ascending
  cholangitis
• Liver disorders
• Acute and chronic pancreatitis
• Appendicitis
• Bowel obstruction
• Bowel perforation

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GORD

• Reflux of stomach acid due to LOS weakness
• /- decreased gastric emptying
• Burning retrosternal discomfort worse on lying
  down
• Relieved by antacids
• Predisposing factors
• LOS dysfunction
• Hiatus hernia (not everyone with hiatus hernia
  will have GORD)
• Obesity

• Smoking
• Pregnancy

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Investigations

• Clinical diagnosis
• Red flag symptoms
• Weight loss
• Dysphagia
• Age gt55
• OGD (Oesophago-gastro duodenoscopy)
• Barium swallow

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Management

• Lifestyle alterations
• weight loss, stop smoking, reduce alcohol
• Antacids e.g. Gaviscon
• PPIs omeprazole, lamsoprazole
• H2 receptor antagonist Ranitidine

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Complications of GORD

• Barretts oesophagus
• Benign oesophageal stricture
• Due to fibrosis
• Can cause dysphagia worse for solids than
  liquids
• endoscopic dilatation and long term PPI

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Barretts Oesophagus

• Metaplasia
• When normal squamous epithelium replaced by
  columnar epithelium like that found in stomach
• IRREVERSIBLE
• 40-fold increased risk of oesophageal
  adenocarcinoma
• Diagnosis based on endoscopic appearance biopsy
  showing metaplasia
• Management long term high dose PPI regular
  endoscopy biopsy

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Gastroenteritis

• Causes diarrhoea and vomiting
• Bacteria, virus or protozoa
• Contaminated food /water
• Most cases self limiting
• Children, elderly, travellers, those on PPIs more
  at risk
• Do stool sample for culture and microscopy if
• immunocompromised
• IBD
• Bloody diarrhoea
• Diarrhoea gt 7 days
• Management adequate hydration. Consider
  anti-motility agent (loperamide)

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Causative Organisms

• Bacterial
• E.coli
• Staph. Aureus
• Salmonella
• Shigella
• C.difficile
• Cholera
• Campylobacter jejuni

• Viral
• Norovirus
• Rotavirus
• Adenovirus

• Protozoa
• Giardia lamblia
• Entamoeba histolytica

NB Food poisoning is a notifiable disease!!
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Peptic ulcer disease
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Peptic ulcer disease

• H. pylori
• NSAIDs / Aspirin
• Alcohol
• Smoking

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Peptic Ulcer Disease
Gastric Ulcer Duodenal Ulcer
Site
Pain worst
Character
Associated symptoms
Relieved by
Weight
Epidemiology
Complications
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Peptic Ulcer Disease
Gastric Ulcer Duodenal Ulcer
Site Epigastric Epigastric
Pain worst Immediately after food (5mins) At night/empty stomach
Character Burning Burning
Associated symptoms Nausea, vomiting (coffee ground), haematemesis, anorexia Malaena,
Relieved by Antacids Antacids/food
Weight Loss No change
Epidemiology Less common (2-3x less than DU) Common (10-15)
Complications Haematemesis, perforation Perforation (anterior) Haemorrhage (posterior)
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Investigations

• H.Pylori test
• Urea breath test (administer radiolabelled urea,
  presence of H. Pylori breaks down urea into NH3
  and CO2- detect radiolabelled CO2)
• Stool antigen test
• Sensitivity 97.6, Specificity 96
• PPIs must be stopped a week before as can lead
  to false negatives

• If gt55 and new onset dyspepsia not accounted for
  by NSAID use
• Or
• Red flag symptoms
• Urgent Endoscopy

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Treatment

• Triple therapy if H.pylori
• PPI
• Amoxicillin
• Clarithromycin
• Stop NSAIDs
• PPI
• H2 antagonist
• Stop smoking

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Ulcerative Colitis

• 15-30 years
• Continuous Inflammation of colonic mucosa
• Relapsing and remitting condition
• Mainly affects the sigmoid colon and rectum,
  rarely affects ileum
• Less common in smokers (opposite in Crohns)

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Ulcerative Colitis

• Diarrhoea blood mucous
• Crampy abdo discomfort
• Weight loss
• Urgency
• Tenesmus

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Investigations

• Bloods FBC, LFTs, CRP, ESR, UE, BCs
• Stool culture (exclude infection)
• AXR mucosal thickening
• CXR rule out perforation
• Sigmoidoscopy inflamed friable mucosa
• Rectal biopsy goblet cell depletion, crypt
  abscesses, mucosal ulcers
• Colonscopy

• ?WCC
• ? ESR
• ?CRP
• Iron deficiency anaemia
• Hypoalbuminaemia in severe disease

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Management

• Medical
• Steroids oral prednisolone
• Immunosuppressant Azathioprine
• Metronidazole
• Methotrexate
• MAB Anti TNF alpha antibody Infliximab

• Surgical
• When medical therapy has failed
• 20 will need surgery
• Remove whole colon colectomy terminal
  ileostomy
• Operate if perforation or toxic megacolon

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Crohns

• Chronic inflammatory disorder
• Skip lesions
• Trasmural and granulomatous inflammation
• Can affect any part of gut from mouth to anus
• Terminal ileum most commonly affected (50)
• More common in smokers
• Genetic association stronger in Crohns

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Signs and Symptoms

• Diarrhoea
• Abdominal pain/tenderness
• Weight loss
• Mouth ulcers
• Anal tags/strictures
• Right iliac fossa mass / pain (terminal ileum)

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Investigations

• Bloods FBC,UE, CRP, LFTs, BCs, B12, folate
• Stool culture to exclude infection
• Sigmoidscopy
• Rectal biopsy
• Capsule endoscopy
• Colonoscopy to asses extent of disease

• ? ESR
• ? CRP
• ? WCC
• Hypoalbuminaemia
• ? B12 or folate
• ? HB

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Management

• Low residue diet (low fibre to slow transit
  time)
• Steroids prednisolone
• Immunosuppressants azathioprine
• Metronidazole
• Methotrexate
• Infliximab
• Surgery

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UC vs Crohns
UC Crohns
Colon only Any part of GI tract from mouth to anus
Continuous inflammation Skip lesions
Mucosal submucosal inflammation Transmural inflammation
No granulomas Granulomas
Crypt abscesses Crypt abscesses
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Extra intestinal signs of IBD

• Uveitis
• Conjunctivitis
• Mouth ulcers
• Clubbing
• Arthralgia
• Arthritis
• Erythema nodosum
• Pyoderma gangrenosum
• Sclerosing cholangitis

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Coeliac Disease

• T- cell mediated autoimmune disease of small
  intestine
• Malabsorption
• Leads to production of anti endomysial antibody
• Antibody attacks tissue transglutaminase enzyme
  that breaks down gluten
• HLA DQ2 associated

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Signs and Symptoms

• Tiredness (iron deficiency anaemia due to
  malabsorption)
• Diarrhoea
• Steatorrhoea
• Weight loss
• Bloating
• Aphthous ulcers
• Angular stomatitis from B12 deficiency
• Osteomalaia

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Investigations

• Duodenal biopsy at endoscopy
• Histologically
• Crypt hypertrophy
• Villous atrophy
• Treatment is with lifelong gluten free diet

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Question

• What is the diagnosis?
• Name four risk factors.
• What histological changes have taken place?
• What common sequelae occurs from this condition?

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Question
A Large bowel obstruction H Aortic dissection
B Acute pancreatitis I Diverticulosis
C Perforated viscus J Duodenal ulcer
D Appendicitis K Renal colic
E Small bowel obstruction L Colorectal carcinoma
F Acute cholecystitis M Mesenteric adenitis
G Ulcerative colitis
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1.
A Large bowel obstruction H Aortic dissection
B Acute pancreatitis I Diverticulosis
C Perforated viscus J Duodenal ulcer
D Appendicitis K Renal colic
E Small bowel obstruction L Colorectal carcinoma
F Acute cholecystitis M Mesenteric adenitis
G Ulcerative colitis
50 year old man presents with epigastric pain
worse at night and relieved by eating, or
drinking milk.
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2.
A Hepatitis H Crohns disease
B Irritable bowel syndrome I Primary biliary cirrhosis
C Umbilical hernia J Carcinoma of sigmoid colon
D Primary sclerosing cholangitis K Acute appendicitis
E Perforated duodenal ulcer L Gastric ulcer
F Small bowel obstruction M Pneumothorax
G Ulcerative colitis
21 year old student presents with cramping
diffuse abdominal pain associated with
alternating constipation and diarrhoea.
Investigations are normal.
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3
A Hepatitis H Crohns disease
B Irritable bowel syndrome I Primary biliary cirrhosis
C Umbilical hernia J Carcinoma of sigmoid colon
D Primary sclerosing cholangitis K Acute appendicitis
E Perforated duodenal ulcer L Gastric ulcer
F Small bowel obstruction M Pneumothorax
G Ulcerative colitis
55 year old smoker presents with severe
epigastric pain. Chest x-ray reveals air under
the diaphragm.
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4.
A Hepatitis H Crohns disease
B Irritable bowel syndrome I Primary biliary cirrhosis
C Umbilical hernia J Carcinoma of sigmoid colon
D Primary sclerosing cholangitis K Acute appendicitis
E Perforated duodenal ulcer L Gastric ulcer
F Small bowel obstruction M Pneumothorax
G Ulcerative colitis
35 year old man presents with weight loss,
diarrhoea and abdominal pain. On examination, he
has apthous ulcers in the mouth and a mass is
palpable in the R iliac fossa. Blood tests reveal
low serum vit B12and folate.
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or misleading information