phase 2 simon berry + mary preston the peer teaching society is not liable for false or misleading...

Phase 2

Simon Berry + Mary Preston

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

• To give a brief overview of the following 4 topics:– Gasto-oesophageal refux disease (GORD)– Inflammatory Bowel Disease– Gastroenteritis– Coeliac Disease

• Apply the knowledge to practice exam questions


Aims

Gastro-oesophageal Reflux Disease (GORD)

• A certain amount of gastro-oesophageal reflux of acid is normal and there is a natural protective mechanism

• If reflux is prolonged or excessive it may cause breakdown of this protection with– Inflammation of the oesophagus – oesophagitis– Benign oesophageal stricture– Barrett’s Oesophagus


Introduction

• Lower oesophageal sphincter in distal oesophagus is in a state of tonic contraction and relaxes transiently to allow passage of food bolus

• Oesophageal mucosal defence mechanisms: mucus and unstirred water layer trap bicarbonate

• Bicarbonate buffers acid in cells and intracellular spaces


Pathophysiology

• 2-3 male to 1 female

• Risk factors:– Increased intra-abdominal pressure– Inadequate lower oesophageal sphincter for anatomical reasons or factors that

reduce tone– Smoking, alcohol, fat, coffee– Pregnancy– Obesity– Big meals– Systemic sclerosis– Hiatus hernia– Drugs eg tricyclic antidepressants, anticholinergics, nitrates and calcium-channel

blockers


Epidemiology

• Heartburn– Burning feeling– Rising from stomach or lower chest up towards the neck– Related to meals– Lying down, stooping and straining– Relieved by antacids

• Retrosternal discomfort• Water brash – excessive salivation• Odynophagia (pain on swallowing) – due to severe oesophagitis or

stricture• Atypical symptoms: cough, chest pain, asthmatic symptoms


Clinical presentation

• Endoscopy– Savary-Miller grading 1-5 or Los Angeles A to D

• FBC – to exclude significant anaemia• Barium swallow – may show hiatus hernia• Oesophageal pH monitoring


Diagnostic tests

• Conservative management– Reduce weight– Stop smoking– Reduce alcohol intake– Raise head of bed at night– Take small regular meals– Avoid hot drinks, alcohol, eating during three hours before bed– Avoid drugs that affect oesophageal motility or damage mucosa– Avoid citrus fruits, tomatoes, onions, spicy foods, soft drinks etc


Management

• Pharmacological:– Full dose Proton Pump Inhibitors (PPIs) for one month– -ZOLE Eg omeprazaole, lanzoprazole, esomeprazole, pantoprazole

etc– If symptoms return after treatment, long-term acid suppression– H.pylori eradication if evident on serology or urea breath test

• Refer to endoscopy if fails to respond to therapy or new emergent symptoms

• Surgery is very late step


Management

• Over the counter medicines– Antacids eg aluminium hydroxide, magnesium carbonate,

magnesium trisilicate– Alginates eg sodium alginate and alginic acid

• H2-receptor antagonists– Eg cimetidine, famotidine, nizatidine, ranitidine


Alternative pharmacological treatments

• For upper GI cancer:– Dysphagia - food sticking on swallowing, at any age.– Dyspepsia at any age combined with one or more of the following 'alarm'

symptoms: Weight loss, Proven anaemia, Vomiting– Dyspepsia in a patient aged 55 years or more with at least one of the following

'high-risk' features: Onset of dyspepsia <1 year previously, Continuous symptoms since onset

– Dyspepsia combined with at least one of the following known 'risk factors':• Family history of upper GI cancer in more than two first-degree relatives• Barrett's oesophagitis• Pernicious anaemia• Peptic ulcer surgery over 20 years previously• Known dysplasia, atrophic gastritis, intestinal metaplasia• Jaundice• Upper abdominal mass


RED FLAGS

Inflammatory Bowel Disease

• Group of inflammatory conditions of colon and small intestine

• Can also affect and part of digestive tract e.g mouth, oesophagus, anus

• Main 2 types are Crohn’s and Ulcerative colitis

Introduction

Ulcerative colitis• Equal in men and

women• Less common in

smokers• Peaks 15-25 ad 60-80

Crohn’s• More commone in

women• More common in

smokers• Peaks 15-30 and 60-80

Who gets it?

UC• Bloody diarrhoea• Abdo pain, urgency,

tenesmus• Can be just in the

rectum(proctitis)-constipation and rectal bleeding

• Systemic symptoms-joints, eyes, malaise, fever, weight loss

Crohn’s• Bloody diarrhoea, abdo

pain, weight loss• Systemic symptoms-

mouth/skin/eyes/joints/perianal ulcers/fissures

• Malaise, anorexia, fever

What are the symptoms?

UC• Abdo:Pain, tenderness,

palpable masses• Tachcardia, hypotension,

febrile (severe)• If pain and distension ?toxic

megacolon

Crohn’s• Signs of weight loss,

anaemia, dehydration• Hypotension, tachcardia,

dehydration• Abdo tenderness and

distension• Anal and perianal lesions• Mouth ulcers

Anything to see on examination?

• Joint diseases: type 1 (pauci-articular) and type 2 (polyarticular)

• Type 1: acute, self-limiting (<10 weeks) and occur with IBD relapses

• Type 2: Arthropathy lasts longer (months to years), independent of IBD activity, usually associated with uveitis

• Eyes: uveitis, episcleritis, conjunctivitis• Skin: erythema nodosum, pyoderma gangrenosum• Liver: sclerosing cholangitis• Nephrolithiasis in Crohn’s (oxalate stones in patients with

small bowel disease or after resection)• Clubbing

Extraintestinal bits and pieces

UC• Restricted to the colon

and rectum• Only affects mucosa• Backwash ileitis• Crypt abscesses

Crohn’s• Can affect any part of

the gastrointestinal tract (skip lesions)

• Affects full thickness of bowel wall (transmural lesions)

• Granulomas• Cobblestone mucosa-

deep fissured ulcers

Histopathology

• Colonoscopy• Biopsy histology• Stool samples for gastroenteritis• Bloods• Abdo imaging-for toxic

megacolon/perforation

How do I investigate?

• If mild – smoking cessation• Mesalazine – for mild/moderate active Crohn’s• Corticosteroids – to induce remission• Symptomatic rx – eg loperamide, bile acid sequestrants, antispasmodics

• Immunomodulators eg azathioprine, mercaptopurine or methotrexate

• Cytokine modulators (TNF-α) eg infliximab• Surgery

How do I treat it? – Crohn’s

• Aminosalicylate eg Mesalazine (5-ASA)• Corticosteroids – relapses of UC, NOT maintenance• Thiopurines eg azathioprine• Ciclosporin• Infliximab• Surgery – 30%, colectomy is curative

How do I treat it? – UC

• ↑incidence of bowel cancer• Toxic megacolon• Pouchitis

Complications

Gastroenteritis

• Most common form of acute gastrointestinal infection

• Combinations of nausea, vomiting, diarrhoea and abdominal pain


Introduction

• 20% UK population develop infectious intestinal disease each year

• Viral causes: norovirus, rotavirus, adenovirus• Bacterial: Campylobacter spp, E. coli O157,

Salmonella spp. Shigella Spp. O toxins from Staph. Aureus, Bacillus cereus or Clostridium perfringens

• Parasitic pathogens: Crytosporidium spp. Entamoeba histolytica (amoebiasis) or Giardia lamblia


Epidemiology + Aetiology

• Mechanisms:– Mucosal adherence -> secretory diarrhoea– Mucosal invasion - > dysentery = low-volume bloody

diarrhoea with abdominal pain– Toxin production

• Two broad syndromes– Watery diarrhoea – usually due to enterotoxins or

adherence– Dysentery – due to mucosal invasion


Pathophysiology

• Need to learn a little about these (microbiology time!)

• Dysentery: Shigella, Enterohaemorrhagic E.coli (EHEC), ?Salmonella, C.difficile

• Watery diarrhoea: Bacillus, Campylobacter jejuni, Vibrio cholerae, Yersiniosis, Staph Aureus


Organisms

• Poor personal hygiene and lack of sanitation• Compromised immune system eg AIDS• Achlorhydria increases risk• Poorly cooked food, cooked food left too long at

room temperature or from uncooked food eg shellfish

• Reheating


Risk Factors

• Incubation periods:– Viruses: a day– Bacillary dysentery: few hours to 4 days– Parasites: 7-10 days

• Epidemics usually caused by a rotavirus or norovirus ‘winter vomiting’

• Bloody diarrhoea:– ?Bacterial infection: E.coli O157, or after return from exotic location,

E.histiolytica. Also, salmonella spp

• Pyrexia in adults suggests invasive organism


Presentation

• DEHYDRATION– Mild: anorexia, nausea, light-headedness, postural hypotension– Moderate: apathy, tiredness, dizziness, muscle cramps, dry tongue,

sunken eyes, reduced skin eleasticity, postural hypotension, tachycardia, oliguria

– Severe: profound apathy, weakness, confusion, shock, tachycardia, systolic BP < 90mmHg, oliguria or anuria

• Also abdominal exam• Check temperature, blood pressure, pulse rate, and

respiratory rate


Assessment

• Stool investigations– Microscopy (including ova, cysts and parasites), culture

and sensitivity. If:• Blood and/or mucus in stool• Patient is immunocompromised• Patient has recently been abroad to anywhere other than western Europe, North

America, Australia or New Zealand• Diarrhoea has not improved by day 7• Uncertainty about diagnosis

– Unwell patients may need blood tests eg FBC, U+Es


Investigations

• NOTIFICATION: dysentery and food poisoning are notifiable• Admission to hospital? – if vomiting and unable to retain oral

fluids, or there are features of shock or severe dehyation

• Encourage as much fluid intake and eating as possible• Prevent spread of infection eg wash hands thoroughly• Avoid work until 48h diarrhoea and vomiting-free• In developing countries, oral rehydration solution (ORS)


Management

• Cook meat properly. Wash vegetables and salads before eating

• Separate uncooked meats from cooked and ready-to-eat food• Wash chopping boards, knives and other utensils in hot soapy

water immediately after handling any raw meet• Wash hands after going to toilet or handling pets before

eating, drinking or cooking


Prevention

Coeliac Disease

• Immune-mediated, inflammatory systemic disorder provoked by gluten (gliadin) and related prolamines.

• Gluten is a protein found in wheat, rye and barley.

What is it?

• Villous atrophy• Crypt hyperplasia

Pathology

• Associated with HLA DQ2 and DQ8• 1% people in the UK• Rare in Central Africa and Asia

Who gets it?

• Tiredness/SOB (anaemia)• Nonspecific-abdo discomfort, arthralgia,

malaise• Smelly pale poo (Diarrhoea, steatorrhoea,

malabsorption)• Weight loss• Mouth ulcers, angular stomatitis

What are the symptoms?

• Fractures-due to low absorption Ca/Vit D• Abnormal bleeding- Vit K deficiency• DERMATITIS HERPETIFORMIS

Systemic features

• Adenocarcinoma and lymphoma (EATL) of the small bowel

• Ulcerative jejunitis• Strictures

Complications

• Dermatitis herpetiformis• Signs of iron deficiency• Mouth ulcers• Signs of weight loss

Anything to see on examinations?

• Blood tests WHILE STILL ON GLUTEN:• Specific autoantibodies:*IgA anti-tissue transglutaminase antibodies

(tTGAs) *Endomysial antibodies(EMA)Deaminated forms gliadin peptides (DGP)• Full blood count• LFTs (elevated transaminases)

How do I investigate it?

• HLA DQ2/DQ8 typing• Biopsy

How do I investigate it?

• Gluten free diet!• Poor compliance-especially in young people• Refer to dietician and have regular follow ups

to improve compliance

How do I manage it?

Practice Questions

• A 17-year-old man with coeliac disease since childhood is non-compliant with his gluten-free diet. He describes passing oily stools that float in the pan and are difficult to flush away.

• What is the main reason for fat malabsorption in this patient? – (a) Distortion of the Ampulla of Vater impeding pancreatic secretion– (b) Loss of lipase production by the small intestinal epithelium– (c) Mucosal surface area reduction due to villous atrophy– (d) Obstruction of small intestinal lymphatics by lymphocytes– (e) Reduced intestinal transit time because of autonomic stimulation


Practice Question

• A 30-year old man presents 1 week with profuse watery diarrhoea with blood mixed in. He recently returned from a holiday to Portugal. What is the most likely diagnosis: – (a) Diverticulitis– (b) Shigella dysenteriae– (c) Clostridium difficile– (d) Bacillus cereus– (e) Yersinius enterocolitica


Practice Question

Shigella is an infectious cause of blood diarrhoea as well as enterohaemorrhagic E.coli. Diverticulitis may cause similar symptoms but is unlikely due to age of the patient. C.difficile may cause bloody diarrhoea however it is usually preceded by a course of abx. Bacillus and Yersinia typically cause watery diarrhoea

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phase 2 simon berry + mary preston the peer teaching society is not liable for false or misleading...

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peer teaching society

misleading information

oesophageal motility

false o

hiatus hernia oesophageal

lower chest

asthmatic symptoms

stricture atypical symptoms