phase 2 hannah ojidu the peer teaching society is not liable for false or misleading information…

Phase 2

Hannah Ojidu

The Peer Teaching Society is not liable for false or misleading information…

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


What’s covered


What’s not covered

• GI bleeding• GI malignancy • Biliary tract disorders: cholecystitis, ascending

cholangitis • Liver disorders • Acute and chronic pancreatitis• Appendicitis • Bowel obstruction • Bowel perforation

• 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


GORD

Smoking Pregnancy

• Clinical diagnosis • Red flag symptoms Weight loss Dysphagia Age >55 • OGD (Oesophago-gastro duodenoscopy) • Barium swallow


Investigations

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


Management

• Barrett’s oesophagus

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


Complications of GORD

• 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


Barrett’s Oesophagus

• 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 > 7 days • Management = adequate hydration. Consider anti-motility agent

(loperamide)


Gastroenteritis


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!!


Peptic ulcer disease

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


Peptic ulcer disease


Peptic Ulcer Disease

Gastric Ulcer Duodenal Ulcer

Site

Pain worst

Character

Associated symptoms

Relieved by

Weight

Epidemiology

Complications


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)

• 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


Investigations

• If >55 and new onset dyspepsia not accounted for by NSAID use

Or

• Red flag symptoms

Urgent Endoscopy

•Triple therapy if H.pylori– PPI– Amoxicillin– Clarithromycin

•Stop NSAIDs•PPI•H2 antagonist

•Stop smoking


Treatment


• 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)

Ulcerative Colitis

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


Ulcerative Colitis

• Bloods – FBC, LFTs, CRP, ESR, U+E, 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


Investigations

• ↑WCC• ↑ ESR• ↑CRP • Iron deficiency

anaemia • Hypoalbuminaemia in

severe disease

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


Management

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

• 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 Crohn’s


Crohn’s

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


Signs and Symptoms

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


Investigations

• ↑ ESR• ↑ CRP• ↑ WCC• Hypoalbuminaemia• ↓ B12 or folate • ↓ HB

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


Management

UC Crohn’s

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


UC vs Crohns


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

Extra intestinal signs of IBD

• 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


Coeliac Disease

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


Signs and Symptoms

• Duodenal biopsy at endoscopy

• Histologically: Crypt hypertrophy Villous atrophy

Treatment is with lifelong gluten free diet


Investigations


Question

1. What is the diagnosis? 2. Name four risk factors.3. What histological changes

have taken place?4. What common sequelae

occurs from this condition?

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


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



1.

50 year old man presents with epigastric pain worse at night and relieved by eating, or drinking milk.

A Hepatitis H Crohn’s 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



2.

21 year old student presents with cramping diffuse abdominal pain associated with alternating constipation and diarrhoea. Investigations are normal.









3

55 year old smoker presents with severe epigastric pain. Chest x-ray reveals air under the diaphragm.









4.

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.

phase 2 hannah ojidu the peer teaching society is not liable for false or misleading information…

Documents

peer teaching society

misleading information

misleading information

notifiable disease

causes diarrhoea

metaplasia management

gord obesity

long term ppi