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Phase 2 Hannah Ojidu The Peer Teaching Society is not liable for false or misleading information… What’s covered • • • • • • Common causes of abdominal pain GORD Peptic Ulcer disease Inflammatory Bowel Disease Gastroenteritis Coeliac disease The Peer Teaching Society is not liable for false or misleading information… 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 The Peer Teaching Society is not liable for false or misleading information… 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 The Peer Teaching Society is not liable for false or misleading information… Smoking Pregnancy Investigations • Clinical diagnosis • Red flag symptoms Weight loss Dysphagia Age >55 • OGD (Oesophago-gastro duodenoscopy) • Barium swallow The Peer Teaching Society is not liable for false or misleading information… Management • Lifestyle alterations weight loss, stop smoking, reduce alcohol • Antacids e.g. Gaviscon® • PPIs – omeprazole, lamsoprazole • H2 receptor antagonist – Ranitidine The Peer Teaching Society is not liable for false or misleading information… Complications of GORD • Barrett’s oesophagus • Benign oesophageal stricture Due to fibrosis Can cause dysphagia worse for solids than liquids endoscopic dilatation and long term PPI The Peer Teaching Society is not liable for false or misleading information… Barrett’s 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 The Peer Teaching Society is not liable for false or misleading information… 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 > 7 days Management = adequate hydration. Consider anti-motility agent (loperamide) The Peer Teaching Society is not liable for false or misleading information… 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!! The Peer Teaching Society is not liable for false or misleading information… Peptic ulcer disease The Peer Teaching Society is not liable for false or misleading information… Peptic ulcer disease • • • • H. pylori NSAIDs / Aspirin Alcohol Smoking The Peer Teaching Society is not liable for false or misleading information… Peptic Ulcer Disease Gastric Ulcer Site Pain worst Character Associated symptoms Relieved by Weight Epidemiology Complications The Peer Teaching Society is not liable for false or misleading information… Duodenal Ulcer 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) The Peer Teaching Society is not liable for false or misleading information… 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 >55 and new onset dyspepsia not accounted for by NSAID use Or • Red flag symptoms Urgent Endoscopy The Peer Teaching Society is not liable for false or misleading information… Treatment • Triple therapy if H.pylori – PPI – Amoxicillin – Clarithromycin • • • • Stop NSAIDs PPI H2 antagonist Stop smoking The Peer Teaching Society is not liable for false or misleading information… 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) The Peer Teaching Society is not liable for false or misleading information… Ulcerative Colitis • • • • • Diarrhoea + blood + mucous Crampy abdo discomfort Weight loss Urgency Tenesmus The Peer Teaching Society is not liable for false or misleading information… Investigations • • • • • • Bloods – FBC, LFTs, CRP, ESR, U+E, BCs •• ↑WCC ↑ ESR • ↑CRP Stool culture (exclude infection) • Iron deficiency anaemia AXR – mucosal thickening • Hypoalbuminaemia CXR – rule out perforation in severe disease Sigmoidoscopy – inflamed friable mucosa Rectal biopsy – goblet cell depletion, crypt abscesses, mucosal ulcers • Colonscopy The Peer Teaching Society is not liable for false or misleading information… 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 The Peer Teaching Society is not liable for false or misleading information… Crohn’s • • • • • • • 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 The Peer Teaching Society is not liable for false or misleading information… Signs and Symptoms • • • • • • Diarrhoea Abdominal pain/tenderness Weight loss Mouth ulcers Anal tags/strictures Right iliac fossa mass / pain (terminal ileum) The Peer Teaching Society is not liable for false or misleading information… Investigations • • • • • • Bloods – FBC,U+E, CRP, LFTs, BCs, B12, folate Stool culture to exclude infection • ↑ ESR Sigmoidscopy • ↑ CRP • ↑ WCC Rectal biopsy • Hypoalbuminaemia Capsule endoscopy • ↓ B12 or folate Colonoscopy to asses extent of disease • ↓ HB The Peer Teaching Society is not liable for false or misleading information… Management • • • • • • • Low residue diet (low fibre – to slow transit time) Steroids – prednisolone Immunosuppressants – azathioprine Metronidazole Methotrexate Infliximab Surgery The Peer Teaching Society is not liable for false or misleading information… UC vs Crohns 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 The Peer Teaching Society is not liable for false or misleading information… Extra intestinal signs of IBD • • • • • • • • • Uveitis Conjunctivitis Mouth ulcers Clubbing Arthralgia Arthritis Erythema nodosum Pyoderma gangrenosum Sclerosing cholangitis The Peer Teaching Society is not liable for false or misleading information… 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 The Peer Teaching Society is not liable for false or misleading information… Signs and Symptoms • • • • • • • • Tiredness (iron deficiency anaemia due to malabsorption) Diarrhoea Steatorrhoea Weight loss Bloating Aphthous ulcers Angular stomatitis from B12 deficiency Osteomalaia The Peer Teaching Society is not liable for false or misleading information… Investigations • Duodenal biopsy at endoscopy • Histologically: Crypt hypertrophy Villous atrophy Treatment is with lifelong gluten free diet The Peer Teaching Society is not liable for false or misleading information… 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? The Peer Teaching Society is not liable for false or misleading information… 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 The Peer Teaching Society is not liable for false or misleading information… 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. The Peer Teaching Society is not liable for false or misleading information… 2. 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 G Ulcerative colitis 21 year old student presents with cramping diffuse abdominal pain associated with alternating constipation and diarrhoea. Investigations are normal. The Peer Teaching Society is not liable for false or misleading information… 3 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 G Ulcerative colitis 55 year old smoker presents with severe epigastric pain. Chest xray reveals air under the diaphragm. The Peer Teaching Society is not liable for false or misleading information… 4. 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 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. The Peer Teaching Society is not liable for false or misleading information…