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Phase 2
Hannah Ojidu
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What’s covered
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Common causes of abdominal pain
GORD
Peptic Ulcer disease
Inflammatory Bowel Disease
Gastroenteritis
Coeliac disease
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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
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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
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 Smoking
 Pregnancy
Investigations
• Clinical diagnosis
• Red flag symptoms
Weight loss
Dysphagia
Age >55
• 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
• Barrett’s 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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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
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Gastroenteritis
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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)
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Causative Organisms
• Bacterial
 E.coli
 Staph. Aureus
 Salmonella
 Shigella
 C.difficile
 Cholera
 Campylobacter jejuni
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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
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H. pylori
NSAIDs / Aspirin
Alcohol
Smoking
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Peptic Ulcer Disease
Gastric Ulcer
Site
Pain worst
Character
Associated
symptoms
Relieved by
Weight
Epidemiology
Complications
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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)
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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 >55 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
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Stop NSAIDs
PPI
H2 antagonist
Stop smoking
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Ulcerative Colitis
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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
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Diarrhoea + blood + mucous
Crampy abdo discomfort
Weight loss
Urgency
Tenesmus
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Investigations
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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
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Management
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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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Crohn’s
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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
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Signs and Symptoms
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Diarrhoea
Abdominal pain/tenderness
Weight loss
Mouth ulcers
Anal tags/strictures
Right iliac fossa mass / pain (terminal ileum)
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Investigations
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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
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Management
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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
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
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Extra intestinal signs of IBD
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Uveitis
Conjunctivitis
Mouth ulcers
Clubbing
Arthralgia
Arthritis
Erythema nodosum
Pyoderma gangrenosum
Sclerosing cholangitis
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Coeliac Disease
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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
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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
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?
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Question
A
Large bowel obstruction
H
Aortic dissection
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Acute pancreatitis
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Diverticulosis
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Perforated viscus
J
Duodenal ulcer
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Appendicitis
K
Renal colic
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Small bowel obstruction
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Colorectal carcinoma
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Acute cholecystitis
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Mesenteric adenitis
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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
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.
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3
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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.
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4.
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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.
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