1. Phase 2 Hannah Ojidu The Peer Teaching Society is not liable for false or misleading information…

2. 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 covered

3. 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

4. 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… GORD  Smoking  Pregnancy

5. 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… Investigations

6. 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… Management

7. 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… Complications of GORD

8. 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… Barrett’s Oesophagus

9. 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… Gastroenteritis

10. 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!!

11. The Peer Teaching Society is not liable for false or misleading information… Peptic ulcer disease

12. H. pylori NSAIDs / Aspirin Alcohol Smoking The Peer Teaching Society is not liable for false or misleading information… Peptic ulcer disease

13. The Peer Teaching Society is not liable for false or misleading information… Peptic Ulcer Disease Gastric UlcerDuodenal Ulcer Site Pain worst Character Associated symptoms Relieved by Weight Epidemiology Complications

14. The Peer Teaching Society is not liable for false or misleading information… Peptic Ulcer Disease Gastric UlcerDuodenal Ulcer SiteEpigastric Pain worstImmediately after food (5mins)At night/empty stomach CharacterBurning Associated symptoms Nausea, vomiting (coffee ground), haematemesis, anorexia Malaena, Relieved byAntacidsAntacids/food WeightLossNo change EpidemiologyLess common (2-3x less than DU)Common (10-15%) ComplicationsHaematemesis, perforationPerforation (anterior) Haemorrhage (posterior)

15. H.Pylori test – Urea breath test (administer radiolabelled urea, presence of H. Pylori breaks down urea into NH 3 and CO 2 - detect radiolabelled CO 2 ) – Stool antigen test Sensitivity 97.6%, Specificity 96% PPIs must be stopped a week before as can lead to false negatives The Peer Teaching Society is not liable for false or misleading information… Investigations If >55 and new onset dyspepsia not accounted for by NSAID use Or Red flag symptoms Urgent Endoscopy

16. Triple therapy if H.pylori – PPI – Amoxicillin – Clarithromycin Stop NSAIDs PPI H 2 antagonist Stop smoking The Peer Teaching Society is not liable for false or misleading information… Treatment

17. The Peer Teaching Society is not liable for false or misleading information… 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) Ulcerative Colitis

18. Diarrhoea + blood + mucous Crampy abdo discomfort Weight loss Urgency Tenesmus The Peer Teaching Society is not liable for false or misleading information… Ulcerative Colitis

19. Bloods – FBC, LFTs, CRP, ESR, U+E, BCs Stool culture (exclude infection) AXR – mucosal thickening CXR – rule out perforation 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… Investigations ↑WCC ↑ ESR ↑CRP Iron deficiency anaemia Hypoalbuminaemia in severe disease

20. Medical Steroids – oral prednisolone Immunosuppressant – Azathioprine Metronidazole Methotrexate MAB – Anti TNF alpha antibody – Infliximab The Peer Teaching Society is not liable for false or misleading information… Management Surgical When medical therapy has failed 20% will need surgery Remove whole colon – colectomy + terminal ileostomy Operate if perforation or toxic megacolon

21. 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… Crohn’s

22. 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… Signs and Symptoms

23. Bloods – FBC,U+E, CRP, LFTs, BCs, B12, folate Stool culture to exclude infection Sigmoidscopy Rectal biopsy Capsule endoscopy Colonoscopy to asses extent of disease The Peer Teaching Society is not liable for false or misleading information… Investigations ↑ ESR ↑ CRP ↑ WCC Hypoalbuminaemia ↓ B12 or folate ↓ HB

24. 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… Management

25. UCCrohn’s Colon onlyAny part of GI tract from mouth to anus Continuous inflammationSkip lesions Mucosal + submucosal inflammationTransmural inflammation No granulomasGranulomas Crypt abscesses The Peer Teaching Society is not liable for false or misleading information… UC vs Crohns

26. The Peer Teaching Society is not liable for false or misleading information… Uveitis Conjunctivitis Mouth ulcers Clubbing Arthralgia Arthritis Erythema nodosum Pyoderma gangrenosum Sclerosing cholangitis Extra intestinal signs of IBD

27. 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… Coeliac Disease

28. 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… Signs and Symptoms

29. 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… Investigations

30. 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?

31. ALarge bowel obstructionHAortic dissection BAcute pancreatitisIDiverticulosis CPerforated viscusJDuodenal ulcer DAppendicitisKRenal colic ESmall bowel obstructionLColorectal carcinoma FAcute cholecystitisMMesenteric adenitis GUlcerative colitis The Peer Teaching Society is not liable for false or misleading information… Question

32. ALarge bowel obstructionHAortic dissection BAcute pancreatitisIDiverticulosis CPerforated viscusJDuodenal ulcer DAppendicitisKRenal colic ESmall bowel obstructionLColorectal carcinoma FAcute cholecystitisMMesenteric adenitis GUlcerative colitis The Peer Teaching Society is not liable for false or misleading information… 1. 50 year old man presents with epigastric pain worse at night and relieved by eating, or drinking milk.

33. AHepatitisHCrohn’s disease BIrritable bowel syndromeIPrimary biliary cirrhosis CUmbilical herniaJCarcinoma of sigmoid colon DPrimary sclerosing cholangitisKAcute appendicitis EPerforated duodenal ulcerLGastric ulcer FSmall bowel obstructionMPneumothorax GUlcerative colitis The Peer Teaching Society is not liable for false or misleading information… 2. 21 year old student presents with cramping diffuse abdominal pain associated with alternating constipation and diarrhoea. Investigations are normal.

34. AHepatitisHCrohn’s disease BIrritable bowel syndromeIPrimary biliary cirrhosis CUmbilical herniaJCarcinoma of sigmoid colon DPrimary sclerosing cholangitisKAcute appendicitis EPerforated duodenal ulcerLGastric ulcer FSmall bowel obstructionMPneumothorax GUlcerative colitis The Peer Teaching Society is not liable for false or misleading information… 3 55 year old smoker presents with severe epigastric pain. Chest x- ray reveals air under the diaphragm.

35. AHepatitisHCrohn’s disease BIrritable bowel syndromeIPrimary biliary cirrhosis CUmbilical herniaJCarcinoma of sigmoid colon DPrimary sclerosing cholangitisKAcute appendicitis EPerforated duodenal ulcerLGastric ulcer FSmall bowel obstructionMPneumothorax GUlcerative colitis The Peer Teaching Society is not liable for false or misleading information… 4. 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 B 12 and folate.