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Transcript of Gastroenterology Www.gr.Dentistbd
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Lectures in Medicine:
Gastroenterology
Associate Professor Alex Boussioutas
Gastroenterologist
Western Hospital/Peter MacCallum Cancer Centre
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Outline
Terminology
Common Gastroenterological problems
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Common terminology Dyspepsia
Epigastric fullness, discomfort, vague term (indigestion)
Dysphagia
Difficulty swallowing, feeling of food sticking in oesophagus
Odynophagia
Painful swallowing usually associated with dysphagia Heartburn
Burning sensation retrosternally associated with reflux
Anorexia
Loss of appetite
Haematemesis
Vomiting blood (could be red or altered coffee ground) Melaena
Passing of black tarry, offensive stool (usually due to upper GI bleeding)
Haematochezia
Passing blood per rectum (PR bleeding)
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Common investigations
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Gastroesophageal Reflux Disease
(GERD/GORD)
Definition: Reflux of gastric contents (acid?) intooesophagus
Symptoms:
May be asymptomatic;
Heartburn +/- retrosternal chest pain
Regurgitation of gastric contents
Acidbrash, waterbrash (watery sensation in mouth)
Atypical chest pain
Nocturnal cough (exacerbation of asthma)
Dysphagia (long term symptoms)
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GERD
Mechanism GOJ incompetence
Due to transient LOS relaxation (tLOSR) (Common GERD)
Hypotensive LOS (More severe GERD)
Anatomical disturbance of LOS (Hiatus Hernia)
Epidemiology Common ~10-20% in West (5% in Asia) for weekly Sx
Exacerbated by: Obesity, caffeine, alcohol, smoking, fattymeal, medication, pregnancy (hormonal/anatomic)
Complications Barretts Oesophagus/malignancy
Ulcers/strictures
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GERD
Investigations
Endoscopy mainstay of diagnosis
Barium Meal not used much may be helpful in
diagnosis of hiatus hernia Manometry/pH studies useful to document reflux
Management
Lifestyle- Cease exacerbators, weight reduction,
posture Medication PPI, H2RAs
Surgery- Hiatus hernia repair
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Dysphagia
Swallowing disorders Dysphagia and Odynophagia
Differential Diagnoses Mechanical obstruction
Benign stricture (Schatzki ring, web, GERD)
Malignant obstruction (SCC, Adenocarcinoma)
Neurological Stroke
Achalasia
MND, Myaesthenia Gravis, Parkinsons
Functional Globus
Management Diagnosis specific and multifactorial
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Peptic Ulcer Disease
Ulceration in regions bathed with acid/pepsin Stomach, Oesophagus, Duodenum, Meckels
Symptoms
Often none Gnawing abdo pain (epigastric)
Vomiting/nausea
Complications
Haemorrhage Perforation/penetration
Gastric outlet obstruction
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Peptic Ulcer
Aetiology
Helicobacter pylori
Up to 90% ofDU and 75% of GU
NSAIDs (Non steroidal antiinflammatory drugs) Physiological stress
Mechanism
Hp infection causing gastrin release and local
inflammation
Loss of mucosal defence, mucous, prostaglandins,blood flow (NSAID)
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Peptic Ulcer
Investigation Non-invasive diagnosis of Hp
Endoscopy
BariumMeal
Management Complications
GI bleed, perforation
Healing the ulcer Eradicate Hp
Treat with PPI Prevent recurrence
Ensure eradication Hp
Longterm PPI prophylaxis if need NSAID (COX-2 selective?)
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Irritable Bowel Syndrome
Abdominal pain associated with altered stools No organic cause identifiable
Epidemiology
Very common ~10% Western population Up to 50% of visits to gastroenterology
Diagnosis Diagnostic criteria somewhat helpful
Rome III criteria Recurrent Abdo pain for 3 days in the last 3 months with 2 of:
Improvement with defecation
Onset associated with change in stool frequency
Onset associated with change in stool form
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IBS
Symptoms include
Bloating, flatus, mucous in stool
Exacerbated by stress
Investigation If typical syndrome in young (50, FHx Abnormal laboratory tests Need to exclude:
In young: Coeliac disease and IBD
In edlerly: Colorectal cancer, Coeliac disease, IBD
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IBS
Management
Supportive, Reassurance and explanation
Symptomatic
Analgaesia (antispasmodic)
Aperient,
Dietary
Psychological Counselling
Antidepressants
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Inflammatory Bowel Disease (IBD)
Crohns Disease Pathology throughout GI tract
Often skip lesions with intervening normal gut
Transmural inflammation and fistulous disease
Ulcerative Colitis Localised to the colon and rectum
Mucosal inflammation characteristic
Usually contiguous disease
Occasionally difficult to distinguish the two Indeterminate Colitis
Epidemiology Incidence in Western countries up to14/100,000
Prevalence in West up to 240/100,000
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IBD
Aetiology Probable polygenic disease
Environmental (gut infection)
Immunological
Symptoms Can be varied depending on site
Often: Diarrhea, abdominal pain, PR bleeding, PR mucous,LOW, LOA
Nutritional disorders Iron deficiency, Vitamin B12 deficiency, Folate deficiency etc
Extraintestinal manifestations Arthritis, Uveitis, Skin changes, Primary Sclerosing Cholangitis
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Crohns Disease
Medical Nutritional replacement
Oral 5-aminosalicylates Sulphasalazine, Mesalazine
Antibiotics Corticosteroids (oral/IV)
Immunomodulators Azathioprine,
Methotrexate
Anti-TNF antibodies Infliximab, Adalumimab
Experimental therapies
Surgical Resection of bowel
Abscess drainage
Fistula repair
Strictureoplasty Management
Multidisciplinary Gastroenterologist
Surgeon
Dietician Nurse
Psychologist
Radiologist
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Management Ulcerative colitis
Medical Nutritional replacement
Topical 5-ASA
Oral 5-aminosalicylates Sulphasalazine, Mesalazine
Antibiotics
Corticosteroids (oral/IV)
Immunomodulators Azathioprine, Cyclosporine
Anti-TNF antibodies Infliximab, Adalumimab
Experimental therapies
Endoscopic Surveillance for CRC
Surgical Resection of bowel
Abscess drainage
Management
Multidisciplinary Gastroenterologist
Surgeon
Dietician
Nurse
Psychologist
Radiologist
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Colorectal Cancer
Epidemiology
Second most common solid cancer globally
Risk related to Age and FHx
Genetic risk
FAP
HNPCC (Lynch Syndrome)
Other Polyposis (MUTYH, Juvenile Polyposis)
Environmental factors
Alcohol, obesity, Diabetes
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Colorectal cancer- genetic syndromes
FAP (Familial Adenomatouspolyposis) Autosomal dominant
Colonic Polyposis (classical>1000 polyps; attenuated>20-100 polyps)
Extracolonic manifestations Gastric Cancer
Duodenal and ampullarycancer
Desmoid disease
Osteoma (commonly ofmandible)
Skin lesions
Lynch Syndrome Autosomal dominant
Most common hereditary Syn
Extracolonic cancers Endometrial cancer
Gastric cancer
Ovarian Cancer Uro-epithelial cancer
Skin lesions (Muir-Torre)
Genetic testing Appropriate referral to
genetic service
Screen FHx Pregentic tests
Genetic test APC gene
MMR genes (MLH1, MSH2,MSH6, PMS2)
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Colorectal cancer - clinical
Symptoms Often none
Altered bowel habit, PR bleeding, LOW, Malaise, Irondeficiency anaemia
Investigation Colonoscopy
Barium Enema/CT colography
Management Part of MDT (Surgeon, Oncologist, Radiologist, Pathologist,
Nurse, Stomaltherapist) Resection
Surveillance
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Colorectal cancer - prevention
Primary prevention-screening Average risk
Population screening at 50 FOBT
Other variations Colonoscopy at 50; Sigmoidoscopy every 5 yrsfrom 50
Moderate risk 1r Relative with CRC 8 years Colonoscopy yearly with surveillance biopsies
High Risk FAP gene carrier
ColonoscopySigmoidoscopy at 12-15yo every 1-2yrs
Gastroscopy/Duodenoscopy
Lynch Syndrome gene carrier Colonoscopy/Gastroscopy at 25 and every 1-2 years
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Coeliac Disease
Immune mediated disease due to allergy to
dietary gluten (protein in wheat, rye, barley)
Pathology Exposure to gluten causes damage to small
intestine leading to malabsorption
Strong genetic association with HLA-DQ2 HLA-DQ8
Environmental factors important
Prevalence 1:100
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Coeliac Disease
Symptoms
GI: diarrhoea, bloating, mouth ulcers, IBS type
Anaemia, Osteoporosis, lethargy Chronic fatigue
Thyroid disease, Type 1 DM
Migraines
Infertility
Abnormal liver function Arthralgia
Asymptomatic
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Coeliac Disease
Diagnosis/Investigation
Coeliac serology Tissue Transglutaminase ab
Endoscopy with small bowel biopsy
Establish diagnosis and assess disease Therapeutic trial
Improvement on gluten free diet
Important in paediatric setting but helpful for adult
Therapy Lifelong gluten free diet
Dietician important