Gastro-intestinal presentations - PowerPoint Presentation

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Gastro-intestinal presentations

Dr Yu Ri Im

MB BChir (Cantab) BSc (Hons) yuri.im@doctors.org.uk14/11/2020

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OverviewAims & objectivesThree key presentationsAbdominal pain: 2 casesNausea and vomiting: 1 caseChange in bowel habit: 1 caseRemember, there are other GI presentations

Some self-study and recall slides to help you remember!

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Aims and objectives Understand common GI presentations – history, examination, Dx! Abdominal pain

Nausea and vomiting PR bleed Constipation and diarrhoea

Understand that there are other manifestations of GI disease E.g. iron deficiency anaemia, jaundice, weight loss  for you to look up

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1) Abdominal pain

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Case 1: Abdominal painA 41-year old female presents with upper abdominal pain, nausea, fever and rigors of two days. She has previously had gallstones. On examination, she has a high BMI of 37. Her HR is 108 bpm, BP 124/76 mmHg, temperature 38.5. She is tender over the epigastrium and right upper quadrant with guarding. Her bloods show WCC 15.8, CRP 156. Her abdominal X-ray is normal.

What is the next best investigation?Ultrasound of abdomenCT of abdomen

MRI of abdomenAmylase levelLiver function tests

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Case 1: Abdominal painA 41-year old female presents with upper abdominal pain, nausea, fever and rigors of two days. She has previously had gallstones. On examination, she has a high BMI of 37. Her HR is 108 bpm, BP 124/76 mmHg, temperature 38.5. She is tender over the epigastrium and right upper quadrant with guarding. Her bloods show WCC 15.8, CRP 156. Her abdominal X-ray is normal.

What is the next best investigation?Ultrasound of abdomenCT of abdomen

MRI of abdomenAmylase levelLiver function tests

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Presentation 1: Abdominal painThinking of differentials!Think of common causes for each anatomical part, e.g. RUQ painThink of surgical sieve, e.g. VITAMIN CDEF,

to cover medical and uncommon causesVascularInfective, InflammatoryT

raumaAutoimmuneMetabolicIatrogenicNeoplasticCongenital

D

rugs,

D

egenerative

E

ndocrine

F

unctional

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Presentation 1: Abdominal pain

Right flank:

Renal colic (kidney stones)Abdominal aortic aneurysmPyelonephritisLeft flank:Renal colic (kidney stones)Abdominal aortic aneurysmPyelonephritis

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Presentation 1: Abdominal painHistoryHPCAsk about SOCRATES

Ask about GI system: think from top to bottom: appetite, early satiety, diet, dysphagia, odynophagia, dyspepsia / reflux, N+V, haematemesis, jaundice, distension, mass, constipation/diarrhoea, PR bleeding (dark stools + haematochezia), tenesmusAsk about GU system: LUTS (lower urinary tract symptoms, e.g. hesitancy, urgency), pain

/burning during micturition, haematuriaAsk about gynae system: vaginal bleeding, discharge, MOSC (menstruation, obstetrics, sexual history, contraception, cervical smear)Ask about constitutional symptoms: weight loss, anorexia, fever, night sweats, pruritus (with jaundice), confusion

PMHx

Ask specifically about problems you suspect, e.g. gallstones

PSHx

Important to ask specifically about abdominal surgery

 adhesions, strictures, recurrence of disease

FHx

DHx

Don’t forget OTC meds, herbals, allergies

Drugs that can cause peptic ulcers: NSAIDs, aspirin, etc.

Drugs that can cause pancreatitis: steroids etc.

Drugs that can cause nausea: opioids

Drugs that cause diarrhoea: antibiotics, laxatives

Drugs that cause constipation: opioids, ondansetron

Antibiotics

 could be causing side effects or

C diff.

infection

SHx

Smoking, alcohol

 serious vascular causes and cancer

Alcohol

 pancreatitis, liver disease

Recreational drugs  hepatitis, HIV

Diet, exercise, sexual history might be relevant

Travel history  gastroenteritis, hepatitis, malaria, TB

Consider systems review

ICE

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Presentation 1: Abdominal painExaminationInspectionAge, cachexia, jaundice, pallor – all that you are taughtAre they lying very still?

 peritonitis?Are they jumping around in pain?  renal colic?Distended? Fluid thrill or shifting dullness +ve = ascites

Pulsatile, expansile mass = AAANeither, soft, bowel sounds tinkling = intestinal obstructionExamine for peritonismPercussion tendernessGuardingRebound tendernessExamine for eponymous signsMurphy’s, McBurney’s, Rovsing’sCullen’s (peri-umbilical bruising), Grey-Turner’s (flank bruising)  pancreatitisIf any stomas or hernias present, examine in more detailDRE

 always offer in exams!

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Presentation 1: Abdominal painInvestigations1) BedsideUrine dipPregnancy testECG

 always if acutely unwell; MI, PE etc. as differential2) Bloods FBC  Hb drop (bleeding?), WCC raised (infection, inflammation)

U+Es  renal function as association with cause (obstruction of kidney), consequence (e.g. dehydration), before tests (CT, contrasted scans) or drugsLFTs  hepatobiliary disease (hepatitis, biliary colic / cholangitis), sepsisCRP  infection, inflammation?Amylase  pancreatitis?Bone profile  if suspicion of pancreatitis high, need this for scoring systemsCoagulation

 if they likely go to theatre soon; also gives idea of liver function

Group + Save

 if they likely go to theatre soon, or suspicion of bleeding

VBG

 lactate (ischaemic colitis? Sepsis?), quick look at Hb (bleeding?), pH, K+ (renal function)

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Presentation 1: Abdominal painInvestigations3) Imaging Depends what you suspect and on your patientAbdominal X-ray

 evidence of bowel obstruction (dilation of bowel loops) + perforationSometimes also shows colitis, kidney stones, etc.

Chest X-ray  air under diaphragm = perforationMight also show medical differentials for upper abdo pain, e.g. pneumoniaUltrasound abdomen  gallstones, biliary duct dilatation, gynaecological pathologyPreferred modality for appendicitis in children and young/pregnant women.CT abdomen  most other causes and consequences of acute abdomen

Usually first line for appendicitis, pancreatitis, kidney stones.

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Diagnosis I: CholecystitisAetiologyAcute gallbladder inflammation90% happen due to cholelithiasis (gallstones) 

calculous cholecystitis5-10% occur just due to dehydration, trauma, sepsis  acalculous cholecystitisFeatures

Presence of risk factors, e.g. PMHx of gallstones, physical inactivity, low fibre dietRUQ painRight shoulder pain (referred)FeverAnorexiaNausea & vomitingO/ERUQ tenderness +/- guardingMurphy’s +vePalpable mass

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Diagnosis I: CholecystitisDiagnosisOften made with ultrasound that is usually first-lineIf severe sepsis, use CT

 gangrenous cholecystitis, gallbladder perforationManagementAnalgesia, antibiotics, IV fluidsIdeally early cholecystectomy during admission (

early/hot cholecystectomy)If this cannot be arranged and patient is improving, cholecystectomy in 6 wksIf this cannot be arranged but patient deteriorates, insert drain (cholecystostomy)

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Diagnosis 1: Acute cholecystitis

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Case 2: Abdominal painA 69-year old male presents with a one-day history of severe abdominal pain. On examination, he is tender in the umbilical area, but there is no guarding. His heart rate is 110 bpm irregular, BP 124/78 mmHg, RR 18 min-1, SpO

2 97% on room air, temperature 37.2 C. His past medical history includes hypertension and a 30-year pack history. He is on ramipril. Are you worried?

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Case 2: Abdominal painA 69-year old male presents with a one-day history of severe abdominal pain. On examination, he is tender in the umbilical area, but there is no guarding. His heart rate is 110 bpm irregular, BP 124/78 mmHg, RR 18 min-1, SpO

2 97% on room air, temperature 37.2 C. His past medical history includes hypertension and a 30-year pack history. He is on ramipril. On his VBG, you notice that the lactate is 7mmol/L (normal <2 mmol/L). This remains high despite IV fluids. What is the most likely diagnosis?Pancreatitis

Biliary sepsisRupture of abdominal aortic aneurysmIschaemic colitisFunctional abdominal pain

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Case 2: Abdominal painA 69-year old male presents with a one-day history of severe abdominal pain. On examination, he is tender in the umbilical area, but there is no guarding. His heart rate is 110 bpm irregular, BP 124/78 mmHg, RR 18 min-1, SpO

2 97% on room air, temperature 37.2 C. His past medical history includes hypertension and a 30-year pack history. He is on ramipril. On his VBG, you notice that the lactate is 7mmol/L (normal <2 mmol/L). This remains high despite IV fluids. What is the most likely diagnosis?Pancreatitis

Biliary sepsisRupture of abdominal aortic aneurysmIschaemic colitisFunctional abdominal pain

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Recall: What do we ask/do for abdominal pain?History?Examination?Investigations?

You must check the lactateYou must consider AAA and ischaemic colitis

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Diagnosis 2: Ischaemic colitisAetiologyPart of “ischaemic bowel disease” = due to acute transient compromise in blood flowCauses: embolus (50% cases), thrombosis, vasculitis, external compression

One of the most serious causes of the “acute abdo,en”Risk factors: cardiovascular disease, especially AF, MI, atherosclerosis, age, smoking, vasculitisHigh mortality – about 60%FeaturesSevere abdominal pain, out of proportion with signs O/E

PR bleeding, diarrhoeaPresence of risk factors, e.g. AF

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Diagnosis 2: Ischaemic colitisDiagnosisCT with

contrast or CT angiogram  diagnosticAXR may show thumbprinting on colon

VBG/ABG shows raised lactateManagementIf no complications  supportive with antibioticsIf infarction, perforation, peritonitis  urgent laparotomy

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Diagnosis 2:

Ischaemic colitis

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Self-study: Abdominal pain overviewMake sure you read all about these for this year!Surgical

abdomenBiliary colic: colicky RUQ pain; no treatment needed if no complicationsCholecystitis: inflammation/infection of gallbladder, usually because of gallstones

 RUQ pain, fever, unwellCholangitis: infection of biliary tree  jaundice, RUQ pain, fever, unwellPancreatitis: epigastric pain radiating to back, N+V, fever, unwell, dehydratedAppendicitis and mimics, e.g. Meckel’s diverticulitis, ectopic pregnancy  RIF pain, can be unwell/feverishDiverticulitis  lower abdo/LIF pain, fever, unwell (c.f. diverticular disease: just pockets, no infection)

Bowel

obstruction

due to 1) mass/cancer, 2) hernia, 3) adhesions

Peptic ulcer disease

, as discussed above

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Self-study: Abdominal pain overviewSurgical emergencies warranting emergency surgeryPeritonitis

due to any of appendicitis, cholecystitis, etc.Bowel perforation due to obstruction, perforating peptic ulcer, toxic megacolon etc.Medical causes of abdominal painGastroenteritis

, read up on the different pathogens and which ones cause bleeding!Hepatitis and other hepatobiliary diseaseIBD (which can also be treated by surgeons if severe)Coeliac diseaseIBS and functional abdominal painsDifferentials, e.g. diabetic ketoacidosis, heart and lung disease (referred from thorax, e.g. myocardial infarction, pneumonia, PE, etc.)

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Self-study: Appendicitis and mimicsAetiologyInfection/inflammation of vermiform appendixFeatures

Migratory pain: first in mid-abdomen, then localises to RIFFever, anorexia, N+VBloods usually show elevated WCC and CRPDiagnosisUsually clinicalCT and US can be helpful in cases of doubtManagement

Conservative/medical (fluids, antibiotics, analgesia) if patient prefers thisSurgical appendicectomy (ideally laparoscopic) in most cases and if complications arise

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Self-study: Appendicitis and mimicsImportant mimicsPregnancy and ectopic pregnancy (RIF!)Meckel’s diverticulitis

Mesenteric adenitis (in children)Any other problems affecting RIF/right flank/even RUQ should be consideredAny other gynae problems, e.g. ovarian cyst rupture, ovarian torsionAny other problems affecting lower abdomen/pelvis

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Self-study: PancreatitisAetiologyInflammatory disorder of exocrine pancreasMany causes (look up “I GET SMASHED” mnemonic)

Most common causes: 1) Alcohol, 2) Gallstones, 3) ERCP (an endoscopic procedure to remove gallstones)FeaturesEpigastric pain radiating to back, of acute onsetNausea & vomiting (80% of patients!)Diagnosis

High amylase (>3x normal) or lipase + clinical pictureIf in doubt, can combine this with CT and other criteriaManagementIV fluids, analgesia, ntutritional support

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Self-study: Diverticular diseaseDefinitionDiverticular disease = diverticulosis

When someone develops diverticuli (outpouchings) of colonOften due to constipationusually asymptomaticDiverticulitisInfection/inflammation of diverticuli

DiagnosisCT or colonoscopy Management of diverticulitisUsually conservative/medical with IV antibioticsIf there are complications, e.g. perforation, patient will need emergency surgery

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Self-study: Abdominal aortic aneurysm (AAA)AetiologyDilation of aorta >1.5x expected

anterio-posterior diameter, usually >3cm90% of all aneurysms arise below renal arteriesMost common in men >60yrsDiagnosisUsually asymptomatic & detected incidentally on a scan or screeningScreening: men who ever smoked get an ultrasound at 65 years

Complication: rupture of AAAIf an AAA ruptures, this is a life-threatening emergency  immediate surgeryPatient presents with triad of:1) Abdominal or back pain2) Shock (hypotension)3) Pulsatile abdominal mass

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Recall slide

Why do you need to ask about past surgical history in patients with abdominal pain?

Describe Murphy’s sign accurately?

Name the diagnostic scan for:

Suspected cholecystitis

Ischaemic colitis

Severe abdominal pain out of proportion with signs could be …?

What blood test will be abnormal in ischaemic colitis?

Name 3 mimics of appendicitis!

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2) Nausea and vomiting

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Case 3: Nausea and vomitingA 73-year old female presents to ED with nausea and vomiting. She has vomited ten times today. Her PMHx includes COPD and hypertension. On examination, her abdomen is distended, but soft, not peritonitic, and bowel sounds are tinkling.

Which first-line scan is indicated?Erect chest X-rayAbdominal X-rayUltrasound of abdomen

CT of abdomenMRI of abdomen

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Case 3: Nausea and vomitingA 73-year old female presents to ED with nausea and vomiting. She has vomited ten times today. Her PMHx includes COPD and hypertension. On examination, her abdomen is distended, but soft, not peritonitic, and bowel sounds are tinkling.

Which first-line scan is indicated?Erect chest X-rayAbdominal X-ray

Ultrasound of abdomenCT of abdomenMRI of abdomen

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Case 3: Nausea and vomiting

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Diagnosis 3:

Sigmoid volvulus

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Presentation 3: Nausea and vomiting (N+V)Can have neurological or peripheral causesMost common

causesGastritis, peptic ulcer disease, GORDGastroenteritis, food poisoningMigraineMotion sicknessVertigo, e.g. benign paroxysmal positional vertigoDrugs, e.g. opioids

Post-operative N+VPregnancyMost serious causes / differentialsThink brain: stroke, brain tumors (increased ICP), brain abscess, meningitisThink bowel: bowel obstruction (many causes), pancreatitis, cholecystitis

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Presentation 3: Nausea and vomitingHistoryHPC Thorough GI history as for abdominal pain, incl. if absolute constipation (obstruction?)Clarify acute-onset vs. long-standing

Clarify colour, amount (quantify), any bloodAsk if progressiveAsk if early morning (raised ICP?)Ask about vertigo, meningism, neurological symptoms if appropriateDHxCheck if they are on any nauseating drugs, e.g. opioids

If you suspect GI cause, remainder as for abdominal pain

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Presentation 3: Nausea and vomitingExaminationAbdominal examinationDistension?Soft, or signs of peritonism?Tinkling bowel sounds?

DRE?  empty rectum typical of obstructionConsider neurological examination, e.g. CNS, if neurological cause more likely

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Presentation 3: Nausea and vomitingInvestigationsIf you suspect other things:Completely depends what you suspectPregnancy possible?

 pregnancy testPeptic ulcer?  H pylori breath test, OGDDKA?  urine dip, blood glucosePancreatitis?  bloods, CT abdomen

Brain cancer/mass/abscess?  CT headCauses for vertigo  either clinical Dx or CT headIf you suspect bowel obstruction:BloodsAXRThen possibly CT to look for the cause

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Diagnosis 3: Bowel obstructionMain causes = HAMHerniasAdhesions

Masses, e.g. cancerVolvulus – usually sigmoid or caecalFeaturesAbdominal distensionNausea, vomitingAbdominal painAbsolute constipation (not passing flatus)

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Diagnosis 3: Bowel obstructionManagementOnce confirmed:Put the patient ‘nil by mouth’ (

NBM)‘Drip and suck’: give IV fluids, insert NG tube and decompress the bowelFurther Rx depends on cause

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Self-study: VolvulusSigmoid > caecalSigmoid = usually counter-clockwiseCaecal = usually

ClockwiseRisk factorsPsychiatric and neurological disordersNursing home residentsChronic constipationPelvic masses, incl. pregnancyAdhesions

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Self-study: VolvulusDxIntestinal obstructionAXR

 coffee beanCT  coffee bean in 3D, should see point of twist, causes, Cx, DDxRxIf no ischaemia, perforation, peritonitis 

endoscopic decompressionIf low and e.g. palliative, can also just do flatus tubeIf ischaemia, perforation, peritonitis  laparotomyHartmann’s for sigmoid, R hemicolectomy for caecalCxObstruction, ischaemia, perforation and peritonitis

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Self-study: Peptic ulcer disease (PUD)AetiologyDescribes disease due to peptic

ulcers formed in the upper GI tract’s mucosaRisk factors: age, obesity, NSAIDs, H pylori infection, smokingFeaturesPresence of risk factorsDyspepsia, often associated with eating; pain may radiate to back and worsen by nightNausea, vomiting

Early satietyManagementStable disease  as for GORD with PPI +/- H pylori eradicationBleeding from ulcer, e.g. haematemesis or melaena  endoscopyPerforated ulcer  emergency surgery

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Self-study: H pyloriAetiologyInfection with bacterium H. pyloriFeatures

As for other peptic ulcer disease (PUD)Management‘H pylori eradication therapy’ = ‘Triple therapy’Usually PPI + two of these three antibiotics: amoxicillin, clarithromycin, metronidazoleThere are lots of other possible and second-line regimens!

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Recall slide

Name a neurological cause causing N+V!

Name an intestinal cause causing N+V!

Name a drug that causes N+V!

3 main causes of bowel obstruction

What’s the first-line imaging for bowel obstruction?

What’s the initial management of bowel obstruction?

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3) Change in bowel habit

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Recall slide

If a patient comes in with change in bowel habit or PR bleed, the history is not that different to the GI history for abdominal pain.

What are the key questions in HPC?

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Case 4: Change in bowel habitA 26-year old female presents with a 6-week history of diarrhoea and fresh rectal bleeding mixed into her stool. She has had mild lower abdominal pains, not always relieved by defaecation. She has lost 3kg during this period and is fatigued. She has no PMHx or FHx of note.

Which would be the gold-standard diagnostic test?Stool culturesAbdominal X-ray

CT of abdomen with contrastMRI of abdomenColonoscopy + biopsy

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Case 4: Change in bowel habitA 26-year old female presents with a 6-week history of diarrhoea and fresh rectal bleeding mixed into her stool. She has had mild lower abdominal pains, not always relieved by defaecation. She has lost 3kg during this period and is fatigued. She has no PMHx or FHx of note.

Which would be the gold-standard diagnostic test?Stool culturesAbdominal X-ray

CT of abdomen with contrastMRI of abdomenColonoscopy + biopsy

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Presentation 4: DiarrhoeaCauses of acute diarrhoea (<2 weeks)GastroenteritisMedications, e.g. antibiotics, laxatives, PPI, antacids, NSAIDs

IBSIBDDiarrhoea of 2-4 weeks is sub-acute and can be caused by eitherCauses of chronic diarrhoea (>4 weeks)IBSIBDCoeliac disease

Medications and drugs, e.g. alcoholColorectal cancerPancreatic insufficiency  steatorrhoea

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Presentation 4: PR bleedingBleeding from GI tract?Haematochezia = bright red PR bleed = probably lower GI tract

Melaena = black stools = probably upper GI tractC.f. haematemesis/coffee-ground vomiting = probably also upper GICauses IBD, especially UCColorectal cancer

Diverticular diseaseIschaemic colitisHaemorrhoidsAnal fissureRarer causes, e.g. angiodysplasia (vessel malformation)Additional things to ask!Bright red or dark?Mixed in?On wiping or in toilet?

How much? (spoons, cups)

Assoc. with painful defaecation?

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Case 4: Change in bowel habitA 26-year old female presents with a 6-week history of diarrhoea and fresh rectal bleeding mixed into her stool. She has had mild lower abdominal pains, not always relieved by defaecation. She has lost 3kg during this period and is fatigued. She has no PMHx or FHx of note.

So which is the most likely diagnosis?Crohn’s diseaseUlcerative colitis

Irritable bowel syndromeIschaemic colitisColorectal cancer

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Case 4: Change in bowel habitA 26-year old female presents with a 6-week history of diarrhoea and fresh rectal bleeding mixed into her stool. She has had mild lower abdominal pains, not always relieved by defaecation. She has lost 3kg during this period and is fatigued. She has no PMHx or FHx of note.

So which is the most likely diagnosis?Crohn’s diseaseUlcerative colitis

Irritable bowel syndromeIschaemic colitisColorectal cancer

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Case 4: Abdominal X-ray

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Diagnosis 4: Ulcerative colitisAetiologyType of inflammatory bowel disease characterised by diffuse inflammation of colonic mucosa and relapsing, remitting course

Usually starts at rectum (proctitis) and ascends more proximallyLinked to risk factors below, colonic bacteria, immune dysfunction, dietPeaks: age 20-40yrs and at 60yrsRisk factorsFHxHLA-B27 gene

NSAIDsInfectionNot smoking

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Diagnosis 4: Ulcerative colitisFeaturesDiarrhoeaPR bleedingLower abdominal pain

Faecal urgencyExtraintestinal manifestationsJoints: sacroiliitis, ankylosing spondylitis, peripheral arthropathyHepatobiliary: primary sclerosing cholangitis (PSC)Skin and mucosa: pyoderma gangrenosum, erythema nodosum, aphthous ulcers

Eye: anterior uveitis, episcleritisHigher risk of colorectal cancer

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Extraintestinal manifestations of UC

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Abdominal

X-ray of complication:

Toxic megacolon

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Diagnosis 4: Ulcerative colitisInvestigationsStool testsFaecal

calprotectin  very high, then prompts colonoscopyConsider cultures  for differentials

BloodsFBC, U+Es, LFTs, CRP, ESR (>30, as inflammatory disorder!)Check LFTs every 6-12 mo to monitor for PSCConsider specialist bloods  pANCA, ASCAAXR  to exclude toxic megacolon (risk of perforation)Consider CT scanConsider double-contrast barium enemaConsider colonoscopy  patients not responding well to Rx

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Diagnosis 4: Ulcerative colitisManagement of acute, non-fulminant episodesSevere if 6+ episodes, HR >90bpm, temp >37.5, low Hb, high ESR

Patient won’t necessarily require admission.Topical + oral mesalazine + oral corticosteroids

Admission + IV corticosteroids+ immunosuppressants, e.g. ciclosporin or infliximab+ colectomy (surgery)

5-aminosalicylic acid (5-ASA)

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Diagnosis 4: Ulcerative colitisManagement of acute, fulminant episodesFulminant = >10 bowel movements/day, continuous or massive bleeding, or severe systemic toxicity, blood Tx requirement, severely dilated colon

Admission + IV corticosteroids, e.g. hydrocortisone 100mg IV TDS/QDS

+ immunosuppressants, e.g. ciclosporin or infliximab+ colectomy (surgery)

If not responding

If not responding within 24-48 hours

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Diagnosis 4: Ulcerative colitisManagement of chronic diseaseOral 5-ASA therapy is required to control disease.Vaccinations should be offered to patients, as they are often immunosuppressed.

InfluenzaPneumococcusHepatitis B in all seronegative patientsHPVVZV if no history of shingles and chickenpox

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Self-study:

Crohn’s vs UC

Main differences

Crohn’s

Diarrhoea +

abdominal pain

typically

Can affect GI tract anywhere and in patches, incl. very top end (mouth ulcers) and bottom end (anus)

Most typically affects terminal ileum



terminal ileitis

Pathology: transmural inflammation, goblet cells, granulomas, giant epithelioid cells

Endoscopy: deep ulcers, skip lesions, ‘cobble-stone’ appearance

More commonly associated with episcleritis

Does not respond well to 5-ASA

Cx: obstruction, caecal volvulus, fistulae, colorectal cancer

UC

Diarrhoea +

PR bleed

typically

Starts with proctitis, then progressively involves colon, but not beyond

Pathology: no inflammation beyond submucosa usually, bifurcated crypts / cryptitis / crypt abscesses, depletion of goblet cells and mucin

Endoscopy: widespread ulceration,

pseudopolyps

More commonly associated with uveitis and PSC

Cx: toxic megacolon, HIGHER risk of colorectal Ca

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Recall slide

3 causes of acute diarrhoea?

3 causes of chronic diarrhoea?

3 causes of PR bleed?

2 extraintestinal manifestations of UC?

2 differences between UC and Crohn’s?

What might be seen on AXR of colitis patients?

Management of acute episode of UC?

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Self-study: Colorectal cancerIf our case 4 was elderly, the most likely diagnosis would be colorectal cancer.Look up:

Aetiology, incl. epidemiology, risk factors, pathophysiologyPresentation/featuresInvestigations and diagnosisManagement options: 1) chemo, 2) radiotherapy, 3) surgery, 4) palliationScreening on the NHS2-week-wait referral pathway

Staging is done by CT chest, abdomen and pelvis and determines treatment (how far has the cancer gone?)Grading is done with histology (how fast does it grow?)

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Self-study: Irritable bowel syndrome (IBS)AetiologyChronic condition characterised by abdominal pain associated with bowel dysfunction

FeaturesAbdominal pain, often relieved by defaecationConstipation, diarrhoea, both can be alternatingBloatingNo red flags e.g. PR bleed, weight lossDiagnosis = clinical; some use ‘

Rome criteria’Management = supportive (analgesia, laxatives, loperamide)

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Self-study: GI infectionsGastroenteritisViralBacterial

 e.g. Campylobacter, Salmonella,

Shigella (bloody diarrhoea)Parasitic  e.g. Giardia; check travel historyClostridium difficile infectionAfter antibiotic use due to disruption of normal bacterial floraRx: Stop offending antibioticsIsolate in sideroomGive metronidazole or vancomycin

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Self-study: Anorectal disorders

The following are worth looking up, as they can cause anorectal pain, itching (pruritus ani), PR bleed +/- change in bowel habit:Haemorrhoids  painless fresh PR bleed, but if infected/thrombosed  painAnal fissure

 e.g. young person who strains a lot after constipation; straining, painful defaecation, fresh PR blood especially on wipingPerineal abscess  painPerineal fistula  painAnal cancer  squamous cancer, associated with HPV infectionOther anorectal disordersPilonidal sinusRectal prolapse

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Wrapping up

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Other manifestations of GI diseaseOther symptoms and disorders for you to look up:DysphagiaDifficulty swallowing; can be oropharyngeal, oesophageal or neurological problem

Look up achalasia, Barrett’s, oesophageal cancer, oesophagitisDyspepsiaEpigastric pain/discomfort, usually associated with eatingLook up the self-study slides on peptic ulcer disease, H. pylori, GORDHaematemesisLook up some of the causes: peptic ulcers, oesophageal varices, Mallory-Weiss tear

Jaundice Hepatobiliary problem, e.g. liver disease, cholangitis, pancreatic CaOr can be due to haemolysis (haematology)Abdominal mass/distensionThink F’s (fat, faeces, fluid, fetus, etc.)  fluid can be ascitesAlways check for pregnancy

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Other manifestations of GI diseaseOther subtle manifestations:Iron deficiency anaemia (suspect GI bleed, exclude cancer!)Pallor

Fatigue, tirednessShortness of breathWeight loss, malnutritionFever, night sweatsGenerally unwellAt the same time, do not forget: GI symptoms can also be associated with or indicative of a different systemic or psychiatric disorder!

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Recall slide

What

must

you investigate for when a patient presents with iron deficiency anaemia?

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Aims and objectives Understand common GI presentations – history, examination, Dx! Abdominal pain  e.g. cases of cholecystitis, ischaemic colitis; many others

Vomiting  e.g. case of bowel obstruction due to sigmoid volvulus PR bleed

 e.g. IBD, colorectal cancer Constipation and diarrhoea e.g. IBD, cancer, IBS Understand that there are other manifestations of GI disease E.g. iron deficiency anaemia, jaundice, weight loss  for you to look up

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Any questions?Happy to share these slides.Please feel free to contact me  yuri.im@doctors.org.uk