GI Revision

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GI Revision

• J Rose

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• Revision is seeing what you have already seen but
  with some hope of understanding it this time.
• A revision lecture is all the other lectures
  shoved together so that the jokes are squeezed
  out.
  
  

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Lecture Plan

• DYSPHAGIA
• JAUNDICE
• DIARRHOEA
• CROHNS DISEASE

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Dysphagia

• No patient ever complained of dysphagia

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What does the patient mean?

• Cant chew properly (mastication)
• Cant get it over (deglutition)
• After swallowing gets stuck (obstructive
  dysphagia) or causes pain (odynophagia)
• Feels full after eating (bloating or satiety)

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Cant chew properly

• Poor teeth, loose dentures, sore gums
• Dry mouth
• Drugs
• Sjögrens
• Weak muscles
• Myasthenia - myopathy - dystrophy

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Cant get it over

• Neuromuscular Incoordination
• Cerebrovascular Disease
• Motor Neurone Disease
• Muscular dystrophy (e.g. myotonic)
• Myasthenia gravis
• Pouches, webs, high strictures
• - Skin disease

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Gets stuck

• Site indicated by time to sticking
• Proximal examination inadequate
• Sticks and goes down lt sticks and comes up
• Progression worrying
• Liquids easier than solids
• Stricture
• Peptic
• Tumour Intrinsic or Extrinsic Ca bronchus
• Connective tissue disease
• CREST/Systemic sclerosis
• Solids and liquids equally affected from the
  start
• Dysmotility
• Persistent - Achalasia
• Intermittent Tertiary contractions,
  presbyoesophagus, nutcracker oesophagus etc.

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Just Hurts

• Oesophagitis
• Candida
• Usually painless. Check under dentures. Angular
  cheilitis. Steroid inhalers.
• Herpes, CMV
• Immunosuppressed.
• Opportunistic
• AIDS
• Reflux
• Acid and bile
• Iatrogenic
• Tubes, ulcerogenic drugs, anticholinergics
• Allergic
• Eosinophilic
• Ulceration
• Malignant
• Adeno- squamous carcinoma
• Extrinsic mediastinal

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Investigations

• Deglutition problems
• Videofluoroscopy with SALT
• Obstructive dysphagia or odynophagia
• Upper GI endoscopy /- biopsy
• Dysmotility
• Barium Meal /- bread or marshmallow barium bolus
• Oesophageal manometry

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Jaundice
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Axioms

• If the sclerae arent yellow its not jaundice
• Carotinaemia?
• detect at around 50micromol/l
• If theres no bile in the urine its not a
  hepatobiliary problem
• Haemolysis
• Gilberts
• Other metabolic disorders of conjugation
• Jaundice with stigmata of CLD is usually due to
  decompensation
• But you might be wrong!
• LFTs are of limited use in diagnosis unless
  absolutely typical of hepatitis or cholestasis
• AST rises first after bile duct obstruction NOT
  Alk Phos
• Abdominal pain followed by jaundice is due to
  gallstones till proved otherwise

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Clinical Signs

• Chronic liver disease
• Palmar erythema

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Clinical Signs

• Chronic liver disease
• Palmar erythema
• Spider naevi

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Clinical Signs

• Chronic liver disease
• Palmar erythema
• Spider naevi
• Leuconychia Bridge nails

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Clinical Signs

• Chronic liver disease
• Palmar erythema
• Spider naevi
• Leuconychia Bridge nails
• Paper money skin
• Loss of body hair gynaecomastia

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Clinical Signs

• Chronic liver disease
• Palmar erythema
• Spider naevi
• Leuconychia Bridge nails
• Paper money skin
• Loss of body hair gynaecomastia
• Dupuytrens contracture

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Signs of Decompensation

• Portal hypertension
• Dilated abdominal veins
• Caput medusae
• Ascites

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Signs of Decompensation

• Portal hypertension
• Dilated abdominal veins
• Caput medusae
• Ascites
• Encephalopathy
• Flap
• Fetor

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Signs of Decompensation

• Portal hypertension
• Dilated abdominal veins
• Caput medusae
• Ascites
• Encephalopathy
• Flap
• Fetor
• Jaundice

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Signs of causes of CLD

• Alcohol
• Parotid enlargement
• Facial telangiectasiae
• Rhinophyma
• Poorly controlled psoriasis

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Signs of causes of CLD

• Alcohol
• Parotid enlargement
• Facial telangiectasiae
• Rhinophyma
• Poorly controlled psoriasis
• Hep B/C
• Tattoos
• Injection sites

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Signs of causes of CLD

• Alcohol
• Parotid enlargement
• Facial telangiectasiae
• Rhinophyma
• Poorly controlled psoriasis
• Hep B/C
• Tattoos
• Injection sites
• NASH
• Raised BMI with central obesity

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Signs of causes of CLD

• Alcohol
• Parotid enlargement
• Facial telangiectasiae
• Rhinophyma
• Poorly controlled psoriasis
• Hep B/C
• Tattoos
• Injection sites
• NASH
• Raised BMI with central obesity
• Haemochromatosis
• Skin colour
• Arthritis

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Signs of causes of CLD

• Alcohol
• Parotid enlargement
• Facial telangiectasiae
• Rhinophyma
• Poorly controlled psoriasis
• Hep B/C
• Tattoos
• Injection sites
• NASH
• Raised BMI with central obesity
• Haemochromatosis
• Skin colour
• Arthritis
• PBC
• Scratch marks
• Pruritus
• Dry eyes
• Xanthelasmata

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Clinical algorithm

• Confirm jaundice and test urine
• Examine for stigmata of CLD and decompensation
• Signs of decompensation increase probability that
  jaundice is due to CLD
• Examine for signs of possible cause
• Consider probability of cause of CLD by age, sex,
  origin and local prevalences.

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Rough prevalences

• Per 100,000 population
• NASH 5000
• Alcohol 500
• Haemochromatosis 250
• Hepatitis C 50
• PBC 20
• iCAH 15
• Hepatitis B 10
• a 1 AT deficiency 5
• Wilsons 1

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Other features

• Haemochromatosis
• Women present later than men
• Biological iron losses
• Immune liver disease
• Women greatly exceed men
• iCAH (SMA IgG) younger than PBC (AMA , IgM)
• PSC (pANCA ) linked to Idiopathic colitis
• Wilsons disease
• Very rare
• Vanishingly rare gt45 years

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No stigmata of CLD

• ULTRASOUND
• dilated ducts
• may miss stones
• CT
• Good for non-biliary pathology pancreas
• MR
• Shows whole of biliary tree
• ERCP
• Therapeutic
• Stones
• Stents
• No dilated ducts
• Acute Intrahepatic
• History
• drugs, occupation, hobbies, contacts
• Viral titres

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Diarrhoea
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What does the patient mean?

• Increased frequency of defaecation
• Wide range of normal
• Usually implies a change
• Altered consistencyIts just not right, doctor
• Something else
• Pre-defaecatory pain
• Urgency/Incontinence/Straining
• Feeling drained
• Timing I cant get out of the house in the
  morning.

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Is it Functional or Organic?
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Functional Disorders

• Altered movement and/or sensitivity of the gut,
  which produces symptoms referable to the part
  affected.
• Organic Diseases
• Demonstrable structural or biochemical
  abnormality of the mucosa, muscle or vasculature
  of the gut or related organs e.g. pancreas.

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Functional Disorder

• Patient not ill
• Pattern of defaecation is normal
• amgtpm As soon as my feet touch the floor,
• pc It just goes right through me,
• rarely at night, rarely incontinent
• Consistency variable and unpredictable
• Symptoms of visceral sensitivity
• Sensation of incomplete evacuation
• Symptoms of smooth muscle dysfunction e.g.
  reflux, flushing, dysmenorrhoea
• Symptoms vary with menstrual cycle
• No abnormal blood tests

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Rome III criteria - IBS

• Recurrent abdominal pain or discomfort at least 3
  days/month in the last 3 months associated with
  two or more of the following
• Improvement with defecation
• Onset associated with a change in frequency of
  stool
• Onset associated with a change in form
  (appearance) of stool

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• Ridges on solid stool indicating high pressure.
• Excess mucus

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Treatment of IBS

• Reassurance
• Check and correct -
• Inadequate diet
• Correctable social factors
• Anxiety/depression
• Visceral sensitivity
• Food intolerances

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IBS-like presentations

• Diverticular disease
• Lactose intolerance
• Milk Intolerance
• Wheat intolerance
• Bile salt malabsorption
• Coeliac disease

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Organic Disease

• Patient may be ill, lost weight etc.
• Loss of normal stool pattern of frequency and
  consistency
• Constant, predictable, unvarying or progressive
• Blood or undigested food in stools
• Sweet corn doesnt count!
• Blood tests may be abnormal
• Low Hb, Alb, raised ESR, CRP

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If probably organic

• Which part of gut is diseased?
• Large bowel or small bowel
• What type of process?
• Inflammatory
• Neoplastic
• Vascular

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Origin of Diarrhoea

• Large bowel
• Pain
• Lower abdomen
• Slow colicky
• Before defaecation
• After food
• Diarrhoea
• Urgent
• Frequent
• Small volumes
• Blood or mucus

• Small bowel
• Pain
• Central
• ?Colicky
• Not closely linked to defaecation or food
• Diarrhoea
• Infrequent
• Large volume
• Steatorrhoea

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Dont Forget

• Recurrent Oral Ulceration
• Coeliac disease
• IBD
• Behçets
• Anaemia implies mucosal disease
• Previous surgery
• Vagotomy
• Gastrectomy/enterostomy
• By-pass
• Small bowel resection

• Foreign travel
• Tropics
• Shigella, Amoeba etc.
• St Petersburg
• Giardia lamblia
• Drugs
• Alcohol
• PPIs
• NSAIDs
• Antibiotics
• Laxatives
• Family History
• Coeliac disease
• IBD

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Archetypes

• Short anaemic patient with oral ulceration
• Coeliac disease
• Decades 2 3 central abdo pain weight loss
• Ileo-caecal Crohns disease
• Painless diarrhoea then mucus then blood but well
• Idiopathic colitis ?distal
• Progressive painful diarrhoea with mucus/pus and
  weight loss
• Young Crohns disease
• Older Colon Carcinoma

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Investigation of suspected organic diarrhoea

• Visualize macro- microscopically the part of
  bowel felt likely to be cause
• Endoscopy/radiology biopsy
• If fails, consider checking other bit. You might
  have been wrong.

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Pitfalls

• Non-specific change on rectal biopsy
• IBD
• Repeated poor bowel prep prevents sigmoidoscopy
• Steatorrhoea
• Pancreatic
• Coeliac
• Watery diarrhoea with negative sigmoidoscopy and
  rectal biopsy
• Colonoscopic biopsies
• Microscopic colitis
• Minimal change (UC)
• Lymphocytic (CD)
• Collagenous (Drugs Bugs)

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Crohns Disease

• Sir T Kennedy Dalziel MB, CM, FFPS (1861-1924)

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Classic patterns

• Terminal ileitis
• Original description
• Unique site
• Tb, Yersinia, lymphoma,
• Bile salts, B12, O.C., warfarin - absorbed
• Caecal backwash
• 2nd 3rd decade
• Strictures, mass
• Ileo-colonic
• Plus caecal disease
• Diffuse ileal
• In children, often as part of panintestinal
  disease
• Distal colonic
• Elderly
• Oro-anal
• Junctional

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Symptoms

• Pain inflammation, ulceration, obstruction
• Diarrhoea SB /or Colonic
• Deficiencies Growth retardation, malnutrition,
  haematinics, protein

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Signs

• Oral ulcers, wasting, abdominal mass, distension,
  anal tags
• Endoscopy
• aphthoid, linear ulcers
• shiny mucosa, pus, little blood
• Histology
• patchy inflammation, extending to submucosa,
  preservation of goblet cells.
• Fissures, granulomas

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Aetiology

• The pathogenesis of Crohn's disease. Mike Ward.
  Lecturer WGH, Edinburgh.
• Lancet 1977ii903-5. 
• Luminal antigen
• Leaky barrier
• Faulty inflammatory process
• 2 3 mostly genetically determined
• 1 will vary from site to site in gut and from
  time to time

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Sites, presentation, antigens
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Sites, presentation, antigens

• Mouth
• Labial swelling, purple discolouration, ulcers,
  cobble stoning
• E numbers, cinnamon, benzoic acid
• Exclusion diet

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Sites, presentation, antigens

• Mouth
• Labial swelling, purple discolouration, ulcers,
  cobble stoning
• E numbers, cinnamon, benzoic acid
• Exclusion diet

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Sites, presentation, antigens

• Mouth
• Labial swelling, purple discolouration, ulcers,
  cobble stoning
• E numbers, cinnamon, benzoic acid
• Exclusion diet
• OGD
• Ulcers (Hp neg)
• Acid
• PPI

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Sites, presentation, antigens

• Mouth
• Labial swelling, purple discolouration, ulcers,
  cobble stoning
• E numbers, cinnamon, benzoic acid
• Exclusion diet
• OGD
• Ulcers (Hp neg)
• Acid
• PPI
• Small bowel
• Oedema, ulcers, fissures, strictures
• Food antigens
• Exclusion diet, oligopeptide diet

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Sites, presentation, antigens

• Mouth
• Labial swelling, purple discolouration, ulcers,
  cobble stoning
• E numbers, cinnamon, benzoic acid
• Exclusion diet
• OGD
• Ulcers (Hp neg)
• Acid
• PPI
• Small bowel
• Oedema, ulcers, fissures, strictures
• Food antigens
• Exclusion diet, oligopeptide diet
• Large bowel
• Aphthoid erosions, linear ulceration,
  cobblestoning
• Bacteria
• Antibiotics metronidazole

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Sites, presentation, antigens

• Mouth
• Labial swelling, purple discolouration, ulcers,
  cobble stoning
• E numbers, cinnamon, benzoic acid
• Exclusion diet
• OGD
• Ulcers (Hp neg)
• Acid
• PPI
• Small bowel
• Oedema, ulcers, fissures, strictures
• Food antigens
• Exclusion diet, oligopeptide diet
• Large bowel
• Aphthoid erosions, linear ulceration,
  cobblestoning
• Bacteria
• Antibiotics metronidazole
• Anal
• Tags, perianal abscesses
• Bacteria

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Treatment

• Lumen
• Eliminate or reduce suspected antigen
• Barrier
• ?diet
• Stop smoking
• Drugs
• Stress
• Inflammation
• Anti-inflammatories
• 5 ASA, steroids.
• Immunosuppressants - 6MP, AZA
• Biologicals - Anti TNF

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Clinical approach

• Is it Crohns or could it be something else?
• Tb, lymphoma, Yersinia, AIDS, Behçets,
  vasculitis, ischaemia
• Where is it?
• Full distribution
• Balance of benefit v intrusion
• Can you chop it out without to much trouble now
  or in future?
• Limited ileal disease
• Advise about drug absorption low dose OC
• Should it go anyway?
• Mass, perforation, penetration, obstruction,
  abscess, fistula, ?Ca (late SB strictures)
• If not, how can you alter the antigen, barrier
  and inflammation?
• What long term strategy?
• Top down v Bottom up

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Good Luck!

• Happy to answer questions now or after the others
  have gone to the pub.

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