GastroenterologyWITH SURGICAL PROBLEMS

Basic Physiology

Investigations – Blood Tests• FBC• U&Es• LFTs• Amylase• ESR/CRP• Auto-Antibodies• Tumour Markers• Arterial Blood Gas• Viral Serology

Anaemias, Raised WCCElectrolyte disturbancesAlbumin, Liver enzymesPancreatic DiseaseImmune ResponseCoeliac diseaseCa 19-9, CEA, AFPAcidosis/Alkalosis, HypoxiaHepatitis antigens

Investigations - Imaging• Abdominal X-ray• CT scan• MRI• Barium Follow-Through/Enema

Investigations - Other• CLO Test• Flexible/Rigid Sigmoidoscopy• Colonoscopy• Endoscopy• Endoscopic Retrograde Cholangiopancreotography• Stool MSC

Scoring Systems• Glasgow-Blatchford Score• Rockall Score• Modified Glasgow Score• Child-Pugh score• MELD score• ALVARADO score• Dukes’ Staging

Gastro-oesophageal Reflux Disease

A 22-year old overweight female presents complaining of a 3-week history of occasional epigastric pain associated with heartburn. It comes on particularly bad after eating spicy food. She smokes 15 cigarettes a day and drinks alcohol most nights.

How do you investigate/initially manage this lady?

Review Medications for a cause

ARE THERE ANY RED FLAG SYMPTOMS?YES

ENDOSCOPY

Test & Treat for H. pylori AND/OR treat with PPI

NO

Lifestyle Advice

Antacids or H2 antagonist

Helicobacter Pylori• 3 options for detection• Carbon-13 urea breath test• Stool Antigen Test• Laboratory-based serology

• Eradication therapy – 7 day course• Full-dose PPI• Metronidazole 400mg and Clarithromycin 250mg BD• Amoxicillin 1g and Clarithromycin 500mg BD

Complications of GORD• Barrett’s oesophagus• Benign oesophageal stricture• Oesophagitis/laryngitis• Ulcerations

Barrett’s Oesophagus

15 years later the same lady comes in complaining of pain and difficulty when swallowing. She also reports persistently vomiting after meals and wretches a lot of the time when she isn’t eating. She has also been losing weight due to being unable to eat. You scan through her history on the computer and note she has repeatedly had to come back for courses of PPIs throughout the years. In the past 15 years there have been no scientific breakthroughs on health problems whatsoever.

Pathology• Metaplasia in the lower portion of the oesophagus• Squamous epithelium replaced by goblet cells in response to chronic

acid exposure• High risk of continued carcinogenesis and leads on to oesophageal

adenocarcinoma

ManagementPatient Support

Oesophagectomy Endoscopic Therapy

Ablative Therapy Mucosal Resection

Further Endoscopic Therapy

Oesophageal CarcinomaDysphagia

VomitingAnorexia

GI Blood Loss

Odynophagia

Hoarseness

Retrosternal Pain

Lymphadenopathy

Intractable Hiccups

• 75% of oesophageal circumference must be involved to become symptomatic• 50% of patients who present due to symptoms already have

unresectable tumour/distant metastases

Investigations• Urgent endoscopy• Staging• CXR• Double-contrast barium swallow• CR/MRI of chest, abdomen, pelvis• Fluorodeoxyglucose positron emission topography (FDG-PET)

ManagementSurgery• Antibiotic & antithrombotic

prophylaxis• Endoscopy• Photodynamic therapy• Ablation• Resection

• Oesophagectomy• Radiotherapy for SCC• Chemotherapy for AC

Palliation• Radiotherapy/chemotherapy• Trastuzumab• Stenting• Liquid feeds, enteral nutrition or

PEG tubes• Pain relief

Oesophageal Varices

A 46-year old male is admitted to A&E following an episode of haematemesis. He smells strongly of alcohol. On admission his observations are: HR 108bpm, BP 135/89, RR 24, SaO2 95% and Temp 37.3°C.

Assessment & Investigations• Glasgow-Blatchford/Rockall Score• CLO test• FBC• U&Es• Coagulation Screen• OGD

Management• Acute Phase• Terlipressin• Prophylactic antibiotics• Endoscopy & Band Ligation

• Prevention• Propranolol

• Consider Transjugular Intrahepatic Portosystemic Shunt if bleeding not controlled

Achalasia

A 27-year old male presents complaining of difficulty swallowing food and bring up food shortly after eating. He reports the problem also happens with liquids, but this has occurred more recently. He has lost some weight over the past few months and had had retro-sternal chest pain.

Investigating Achalasia• OGD• X-ray• Barium Swallow• Oesophageal Manometry

Managing Achalasia• Calcium-channel blockers & nitrates• Pneumatic dilatation• Endoscopic injection of botulinum toxin• Heller myotomy

Gastritis

A 46-year old woman complains of central upper abdominal pain, that does not radiate. The pain is associated with nausea, and she has noticed that she gets full very early. Because of this she is losing her appetite and has lost weight.

Mallory-Weiss Tear

A 27-year old known alcoholic presents to A&E with blood-stained vomiting. He describes it as fresh blood and isn’t sure when it actually started. He said he was out last night and had a lot to drink. A friend informs you that he was vomiting from about 3 in the morning and fresh blood appeared quite late into it.

Peptic Ulcer Disease

A 22-year old female presents complaining of a 3-week history of occasional epigastric pain associated with heartburn. It comes on particularly bad after eating spicy food. She smokes 15 cigarettes a day and drinks alcohol most nights.

Investigations• FBC• CLO testing• Endoscopy

ManagementBehaviour Modification

H pylori-positive

H. pylori-negative, NSAID induced

H pylori-negative, NSAID-negative ulcer

REPEAT ENDOSCOPY

Gastric Adenocarcinoma

The history is basically the same as everything else. RED FLAGS are indication for urgent referral to endoscopy. Not going to talk about investigations because again it’s essentially the same. Just important to remember keep patients free from acid suppression for the 2 weeks and do a full blood count.

Management• Surgery• Subtotal gastrectomy• Total gastrectomy• Local clearance of lymph nodes• Only remove pancreas/spleen if direct invasion!!

• Perioperative combination chemotherapy• 5-fluorouracil = most effective

PalliationObstruction• Stenting• Gastrojejunostomy• Endoscopic laser therapy

Anaemia• Blood transfusions

Haemorrhage• Treat the cancer

Pain• Coeliac plexus nerve blocks

Prognosis• Overall survival 15%• 10-year survival is 11%• If under 50 5-year survival is 15-20%• If over 50 5-12%

MALT Lymphoma

A 62-year old woman presents complaining of long-standing indigestion. She has also been incredibly tired over the past few years, feelsslightly feverish and she notices her clothes have been becoming looser. Her husband informs you he often wakes up in the middle of the night because the sheets are soaking from her sweating. Her temperature is 37.5°C and you note that she has had several respiratory tract infections over the past year or two.

Assessment• FBC, U&Es, LFTs• Phenotyping circulating lymphocytes• Barium contrast studies of upper & lower GI tract• CT/MRI scan• Endoscopy• Bone Marrow Aspiration

StagingIE

IIE

IIIE

IV

L L L

L

Management

PPIH. Pylori Eradication

Gastroenteritis• Assess for dehydration• Investigate potential causes• Assess risk factors & medications• Admt to hospital if vomiting and unable to retain fluids, or features of

shock/severe dehydration• Do not give antidiarrhoeal drugs• Do not give antibiotics• Anti-emetics are usually not necessary

Gastroenteritis• Amoebiasis• Campylobacteriosis• Cryptosporidiosis• E. Coli• Giardiasis• Salmonellosis• Shigellosis

Acute Liver Failure

A 46-year old male presents to A&E jaundiced with a distended abdomen. He has strange bruises all over his body and is very agitated. He does not know where he is and tries to attack one of the nurses.

On examination he is incredibly tender in the upper abdomen and has hepatomegaly. He has a positive shifting dullness and begins to vomit clear fluid.

Workup• FBC• PT/aPTT/INR• LFTs• Bilirubin• Ammonia, Glucose, Lactate, Creatinine, Phosphate• ABG• Blood Cultures• Viral Serology• Autoimmune Markers• Abdominal US/CT

Management ABC

Management of Encephalopathy & Oedema

Management of Coagulopathy

Management• Location• Positioning• Lactulose• Haemodynamic monitoring• Mannitol• Hypothermia

Management of Encephalopathy & Oedema

Management• Monitor INR• FFP• Cryoprecipitate• Recombinant factor VIIa• Platelet transfusions

Management of Coagulopathy

Jaundice

JaundiceHistory Bilirubin ALT AST ALP GGT

Pre-Hepatic

Lethargy/fatigueStressTraumaFamilial history

Raised unconjugated

- - - -

Hepatic Preceding coryzal symptomsMedicationPrevious liver diseaseRisks for viral disease

Raised unconjugated AND conjugated Raised Raised Normal/

Raised Normal

Post-Hepatic

Pale stoolDark urineRUQ pain (can be painless)

Bilirubin present in urineRaised conjugated bilirubin

Raised Raised Raised Raised

The Path to Cirrhosis

Complications of Cirrhosis• Hepatorenal syndrome• Varices• Infection (particularly bacterial peritonitis due to paracentesis)

Viral Hepatitis• Hepatitis viruses• Herpes viruses• Epstein-Barr• Cytomegalovirus• Varicella• Adenovirus• Yellow fever• Haemorrhagic viruses

Effects

Symptoms• Fever• Malaise• Abdo discomfort• Jaundice• 3-6 weeks then subside• ‘Waves’ of symptoms

Signs• Spider naevi• Jaundice• URQ tenderness• Hepatomegaly• Splenomegaly (in EBV/CMV)

A

A 22-year old gap year student presents to you one month after getting back from his trip to Sub-Saharan Africa. He was helping communities that had been damaged by recent flooding, and had stayed in a small hut with 20 locals. He had vague abdominal pain, and felt a bit feverish. This has lasted about 2 weeks and he mentions a lot of his friends have been calling him Bart Simpson as they said he looks a bit yellow.

B

A 45-year old businessman presents 3 months after he returned from a trip to Thailand. He has vague abdominal pain, nausea and vomiting. On examination he is tender in his right upper quadrant and you can feel the liver border quite easily. You note in his history he used IV drugs when he was younger.

Hepatitis B Testing

B

A 45-year old businessman presents 3 months after he returned from a trip to Thailand. He has vague abdominal pain, nausea and vomiting. On examination he is tender in his right upper quadrant and you can feel the liver border quite easily. You note in his history he used IV drugs when he was younger.

C

A 53-year old female presents to you feeling feverish, nauseous and with abdominal pain. She received a blood transfusion in 1989 after a car accident.

Autoimmune Hepatitis

A 17-year old female presents to her GP feeling fatigued, nausea and an all-over itch. Abdominal examination reveals nothing abnormal other than slightly jaundiced sclera.

You take some bloods and her LFTs return deranged showing raised ALT and AST. ALP is normal. She also has a normochromic anaemia.

You decide at this point to test for autoantibodies and refer for a liver biopsy.

She is treated with Prednisolone in conjunction with Azathioprine.

Monitoring• Test for hep A&B vaccinate if needed• Monitor LFTs, glucose and FBC• DEXA scan before starting steroids and repeat 1-2 years• Screen for glaucoma and cataracts after 1 months treatment

Complications• Hyperviscosity syndrome• Hepatocellular carcinoma

Biliary Colic

A 44-year old female presents with intermittent upper abdominal pains. She states they are worse about 2-3 hours after food and it particularly happens after fast food. She does feel a bit nauseous, but she hasn’t actually thrown up from the pain. She has had a few episodes of diarrhoea since the onset of symptoms.

On examination she is tender in her right upper quadrant but Murphy’s sign is negative.

Cholecystitis

The same lady returns one year later with similar symptoms. Her previous ultrasound was inconclusive so she was given analgesia and then her symptoms resolved spontaneously.

She now has pain in her right scapula, and has thrown up from the pain. It has gone from being intermittent to a constant severe pain in the right upper quadrant. Examination reveals a low-grade fever and a positive Murphy’s sign.

Investigations• Ultrasound visualisation• ALP• GGT• WCC

ComplicationsAscending CholangitisRupture/PerforationPseudodiverticular of the gallbladderGallstone Ileus

Investigations & Management• Ultrasound• Pain relief• Lithotripsy• Laparoscopic cholecystectomy

Ascending Cholangitis

A 55-year old man with a history of gallstone disease presents with a two day history of pain in the right upper quadrant. He feels ‘fluey’ and has had a fever. On examination his temperature is 38.0°C, pulse 103/min and blood pressure 105/63 mmHg. He is tender in the right upper quadrant and his sclera are tinged yellow.

Sepsis 6Give 3• High flow oxygen• IV antibiotics• IV fluids

Take 3• Blood cultures• Urine output• Hb/Lactate

Other Investigations (& Management)• Full Blood Count• Liver Function Tests• Ultrasound• ERCP

Raised white cell countRaised bilirubin ALP and GGTDiagnosisERCP – visualise & remove obstruction

Acute Pancreatitis

A 40-year old female is bought into A&E complaining of severe vomiting. It is associated with extreme pain that radiates to the back. She has a past history of gallstones. She is tachycardic, hypertensive, tachypnoeic and apyrexial. Her O2 sats are 94% on air. You notice some unusual bruising in her abdominal flanks.

Other causesIdiopathicGallstonesEthanolTraumaSteroidsMumpsAutoimmuneScorpion venomHyperlipidemia, Hypothermia, HypercalcemiaERCP & emboliDrugs

Investigations• Amylase• FBC, U&E, Glucose, CRP• LFTs• Serum calcium• ABG• Erect X-ray• Ultrasound scan

Management• Pain relief• IV fluids• IV antibiotics if severe pancreatic necrosis• Enteral nutrition• ERCP• Cholecystectomy• Hyperbaric oxygen therapy• Whipple’s procedure

Chronic Pancreatitis

The same 40-year old recovers successfully from her cholecystectomy, but has begun to drink alcohol due to the stress of the episode. She has recurrent episodes of pancreatitis and successfully cuts down her drinking but doesn’t wish to stop.

At the age of 42 she begins to get constant pain deep in the epigastric region radiating to the back. It gets much worse when eating and she feels sick. She has been having steatorrhoea and losing weight.

On examination her fingers are clubbed and you notice a dusky discolouration of the skin over her epigastrium.

Appendicitis

A 17-year old is referred to A&E with acute abdominal pain that began centrally and has migrated over to the right hand side. He has vomited 4 times. On examination his temperature is 37.6°C, he is tender over McBurney’s point and has a positive Psoas sign. There is no evidence of peritonism.

Irritable Bowel Syndrome

A 23-year old goes to the GP complaining of bowel problems. She has always had irregular bowel habits, and they have recently become worse. She notes that she gets a lot of cramping and bloating sensations throughout the day. She often has periods where she is constipated then has loose stools. She has noticed it is particularly worse on Wednesdays when her and her co-workers get a milkshake. She has also been under a lot of stress recently with finances and her husband being busy and unable to help with the children or housework.

Investigations• NO investigation to confirm IBS• Full blood count• ESR/CRP• Antibody testing for coeliac disease

Management• Assess diet & nutrition• Physical activity levels• Psychological status• Dietary advice• Treat constipation/diarrhoea appropriately

Coeliac Disease

A 27-year old male presents feeling tired all the time. Upon further questioning he has had recurrent diarrhoea associated with abdominal cramping and feeling nauseous. You note that blood tests performed a week ago by the practice nurse reveal an iron deficiency anaemia.

Management• Gluten-free diet• Follow-up in secondary care until satisfactory progression on diet is

achieved• Routinely assess:-• BMI• Symptoms• Coeliac Serology• FBC, ferritin, calcium and vitamin D• B12• U&Es• TFTs

ASSESS for osteoporosis• Lifestyle & supplementation advice• DEXA scan

Complications• Anaemia• Hyposlenism• Osteoporosis• Lactose intolerance• Enteropathy-associated T-cell lymphoma of small intestine• Subfertility• Oesophageal Cancer

Crohn’s Disease

A 15-year old attends GP with his mother. He has had a 2-month history of abdominal pain and change in bowel habit. The abdominal pain is the largest problem for him. His mother informs you he has been much more lethargic than usual and it is affecting his school work.

His father had a history of bowel troubles, but they aren’t sure what they were as he left when he was 6 months old. He admits to smoking 10-cigarettes a day regularly for the past 2 years.

On examination he is tender in the right lower quadrant and has some fluctuation of his nail beds.

Complications• Psychological effects• Intestinal strictures• Abscesses in the wall of the intestine• Fistulas• Anaemia• Malnutrition• Colorectal and small bowel cancers

Extra-intestinal manifestations

Related to Disease Activity• Arthritis• Erythema nodosum• Aphthous ulcers• Episcleritis• Metabolic bone disease

Unrelated to Disease Activity• Axial/polyarticular arthritis• Pyoderma gangrenosum• Uveitis• Hepatobiliary conditions• Bronchiectasis/bronchitis

Management of Established Crohn’s

Primary Care Management• Advice and support• Monitor & prescribe recommended drug

treatments• Screen for complications• Manage specific symptom-control issues• Smoking cessation• Discuss colorectal cancer screening• Ensure osteoporosis risk is managed

appropriately

Secondary Care Management• Corticosteroid therapy• Immunosuppresant• Aminosalicylates

Managing ‘Flares’• CRP is raised AND:• Cachexia/dramatic weight loss• Obstruction/abscess• Systemic illness• Persistent symptoms• Severe diarrhoea

• Short course of corticosteroids

Diarrhoea• Symptomatically• Anti-motility drugs• Anti-spasmodic drugs• Bulking agents

• REFER if systemically unwell

• Refer fistulas• Give metronidazole/ciprofloxacin

• Refer suspected obstruction• Likely to require endoscopy/surgery to dilate/excise stricture

• Refer dyspepsia• Follow usual pathway, refer on 2-week wait

• Give topical steroids/immunomodulators for oral disease• Manage pain as normal• AVOID NSAIDs

Ulcerative Colitis

A 57-year old male attends with a year-long history of worsening bowel symptoms. He describes blood diarrhoea, and often having the urge to just go to the toilet. He has had some accidents in public. He describes abdominal pain in the left lower quadrant.

Features

Crohn’s• Diarrhoea usually non-bloody• Weight loss• Upper GI symptoms• Abdominal mass in RIF

Ulcerative Colitis• Bloody diarrhoea• Abdominal pain in the left lower

quadrant• Tenesmus

Complications

Crohn’s• Obstruction• Fistula• Colorectal Cancer

Ulcerative Colitis• Risk of colorectal cancer higher

in UC than CD• Primary sclerosing cholangitis

more common• HLA-B27 disease associations

Pathology

Crohn’s• Lesions seen anywhere from

mouth to anus• Skip lesions

Ulcerative Colitis• Inflammation starts at rectum• Never beyond ileocaecal valve• Continuous disease

Histology

Crohn’s• Inflammation in all layers from

mucosa to serosa• Increased goblet cells• Granulomas

Ulcerative Colitis• No inflammation beyond

submucosa• Neutrophils migrate through

walls of glands to form crypt abscesses• Depletion of goblet cells

Endoscopy

Crohn’s• Deep ulcers• Skip lesions• Cobble-stone appearance

Ulcerative Colitis• Widespread ulceration• Preservation of adjacent mucosa• Pseudopolyps

Radiology

Crohn’s• Small-bowel enema• High sensitivity and specificity• Strictures – Kantor’s string sign• Proximal bowel dilation• Rose thorn ulcers• Fisulae

Ulcerative Colitis• Barium enema• Loss of haustrations• Pseudopolyps• Narrow short colon

Toxic Megacolon• Rare complication of UC• Triggered by:-• Hypokalaemia• Opiates• Anticholinergics• Barium enemas

• Colon becomes acutely dilated and patients are severely ill• IV fluids, IV steroids, antibiotics, IV ciclosporin• May require total colectomy

Diverticular Disease

A 67-year old woman presents complaining of intermittent left iliac fosse pain. Defecation takes considerable straining and she often passes broken pellet-like stools. She is not peritonitic and PR exam reveals nothing.

Hernias

A 72-year old obese male presents with a scrotal swelling. It is not painful but it is quite distressing for him. He can push it back but it returns very easily.

On examination there is a palpable lump, located above and medially to the pubic tubercle. It can be reduced but coughing brings it back. It is not pulsatile and you can hear bowel sounds in the lump.

Inguinal Hernia Anatomy

Management• Elective Hernia Repair• Avoid strangulation/ischaemia• Admit as emergency if suspected

Other hernias• Umbilical• Paraumbilical• Incisional• Diaphragmatic/Hiatus• Epigastric• Obturator• Perineal

Bowel Obstruction

Small Bowel• Colicky pain• Vomiting occurs before

constipation• Bilious vomiting

Large Bowel• Pain lower in abdomen• Spasms last longer• Constipation occurs earlier• Vomiting less prominent• Can be faeculant

Causes

Small Bowel• Adhesions• Hernias• Crohn’s• Neoplasms• Intussusception• Ischaemic strictures

Large Bowel• Neoplasms• Diverticulitis• Hernias• Inflammatory Bowel Diseas• Volvulus• Adhesions

Imaging

Managing Small Bowel Obstruction• Aspirate fluid via Ryles Tube• Imaging• X-ray• Ultrasound• Contrast enema• CT scan

• Antiemetics• Pain relief• Complete obstruction that does not settle requires surgery

Large bowel obstruction• NEED surgical intervention

Colorectal Cancer

Left sided• Change in bowel habits• Obstructive symptoms• Diarrhoea

• Loose stools• Blood in stools

Right sided• Mass• Abdominal pain• Fever• Sweating• Anaemia

Referral• Proforma for 2 week wait• From presenting to GP, decision to treat must be made within 62 days

Investigations• Flexible sigmoidoscopy + barium enema• Colonoscopy• CT Colonography• Endoscopy• BIOPSY

Stage• Contrast enhanced CT chest abdomen pelvis• Stage officially using TNM• Dukes helps with learning prognosis (5-year survival)• A = >90%• B = 70-85%• C = ~30%• D = <5%

• If rectal cancer offer MRI• Assess risk of local recurrence

Management – Local Tumours• MDT discussion• Assess if suitable for local resection• If unresectable offer high dose brachytherapy to reduce tumour bulk

• Offer information• Treatment options• Likelihood of stoma & management

• Laparoscopic surgery

Management – Metastatic Tumours• Bowel cancer commonly spreads to Liver and Lungs• Lungs• Radiofrequency ablation• Cytoreduction surgery

• Liver• Hepatic resection• Microwave ablation

• Chemotherapy• XELOX regime – capecitabine, oxaliplatin• FOLFOX regime – folinic acid, 5-fluorouracil, oxaliplatin

Ongoing Care• Two CTs of chest abdomen pelvis in first three years AND 6 monthly

CEA tests• Surveillance colonoscopy at 1 year• Follow-up after 5-years

Hereditary Nopolyposis Colorectal Cancer• 5% inherited cancers• Autosomal dominant• Mismatch repair gene mutation

• Type 1 = colorectal cancer• Type 2 = + endometrial, ureteric, stomach, small bowel• Regular surveillance once identified

Familial Adenomatous Polyposis• <1% hereditary cancers• Mutation of APC gene• High malignant potential

Peutz-Jegher Syndrome• VERY RARE• Hereditary intestinal polyposis syndrome• Autosomal dominant• Criteria• Family history• Mucocutaneous lesions• Hamartomatous polyps

Anal Fissures• Tear in the internal anal sphincter• Spasm of the internal anal sphincter which worsens the tear• Causes pain and bleeding• Medical – glycerol suppository, lactulose, movicol

Diltiazem cream with nitrate• Surgical – botox injection, lateral sphincterotomy