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GI symptoms, GI diseases - Coggle Diagram

- - - - removal of distal ileum due to (usually) CD
- - - - CD
      - UC
- - - - indigestion
      - oesophageal motility disorders
    - - appendicitis
    - - ascending cholangitis
    - - acute pancreatitis
- - - - fever
      - jaundice
      - RUQ pain
  - - - Female
      - Forty
      - Fat
      - Fertile
- - - - continuous inflammation that only affects the colon, starting from the rectum then spreading proximally
      - goblet cells depleted
      - lots of crypt abscesses
      - limited to mucosa
    - - bloody diarrhoea
      - abdominal pain
      - weight loss
      - fatigue
      - proctitis
        
        frequency
        
        urgency
        
        FI
        
        tenesmus
        
        passing small amounts of blood & mucus
        
        proximal faecal statis
        
        treatment
        
        topical
    - - 20–30% will need colectomy within 10 yrs
      - can develop into acute severe colitis
        
        presentation
        
        6 or more bloody stools a day AND
        
        37.8C or
        
        90bpm or
        
        Hb<105g/L or
        
        ESR>30mm/h or CRP>30mg/L
        
        investigations
        
        bloods for inflammatory markers/anaemia/albumin
        
        decreased albumin
        
        stool culture
        
        4 to rule out infection by C. diff
        
        colonoscopy
        
        mucosal biopsies
        
        faecal calprotectin
        
        50–200 equivocal, >200 positive
        
        AXR to rule out toxic megacolon
        
        treatment
        
        STOP
        
        NSAIDs
        
        opiates
        
        anti-diarrhoeal drugs
        
        anti-cholinergic drugs
        
        high dose IV steroids ± anti-TNF rescue therapy
        
        IV hydration
        
        careful electrolyte correction
        
        low molecular weight heparin
        
        specialist GI assessment within 24 hrs
        
        ~1/3 chance of emergency subtotal colectomy (everything except rectum)
        
        can then have pouch procedure (only recommended for UC) or completion proctectomy
        
        pouchitis can be treated with VSL 3 or probiotics
        
        surgery necessary for those not responding to IV steroids ± anti-TNF rescue therapy
      - high risk of colonic carcinoma (decreased with 5-ASA)
      - ~60% with pancolitis will need colectomy, most within a yr of diagnosis
    - - 5-ASAs (induction [>3g oral daily] & maintenance of remission [>2g per day])
        
        mesalazine
        
        pro-drugs
        
        balsalazide
        
        olzalazine
        
        sulfasalazine
        
        ongoing symptoms despite topical or more extensive disease
        
        oral
        
        topical
        
        proctosigmoiditis
        
        enema
        
        proctitis
        
        suppository
      - induce remission
        
        steroids
        
        prednisolone (40mg per day, taper over 4–8 wks)
        
        calcium/vit D supplements
        
        budesonide
        
        slightly less effective, better side effects
        
        elemental feeding
        
        exclusive elemental feeding can be as effective as steroids
        
        more efficacious in children
      - maintenance
        
        immunomodulation
        
        thiopurines
        
        azathioprine
        
        6-mercaptopurine
        
        used if
        
        intolerant to steroids
        
        2 or more steroid courses in calendar yr
        
        disease relapses when prednisolone <15mg per day
        
        disease relapses within 6 wks of stopping steroids
        
        can check thiopurine S-methyltransferase (TPMT) to assess suitability & aid dosage
        
        biologics (mAbs)
        
        anti-TNF alpha
        
        infliximab (8 wkly IV infusion)
        
        adalimumab (2 wkly SC injections)
        
        alpha 4b7 integrin blockers
        
        vedolizumab (8 wkly IV infusions)
        
        IL12/IL23 blockers
        
        ustekinumab (IV loading followed by SC 8–12 wkly)
        
        Tofacitinib (oral pan JAK 1/3 inhibitor)
  - - - mouth to anus
      - skip lesions
      - granulomas
      - few crypt abscesses
      - transmural inflammation
    - - diarrhoea
      - weight loss
      - abdominal pain
      - fatigue
      - malaise
      - anorexia
      - N&V
      - low-grade fever
      - malabsorption
        
        anaemia
        
        vitamin deficiency
      - perianal
        
        unable to sit down
        
        passing mucus
        
        perianal pain
    - - bloods
        
        inflammatory markers
      - stool culture to rule out infection
      - faecal calprotectin
        
        may not be high if colon not affected
      - colonoscopy with terminal ileum intubation
        
        biopsies of colon & terminal ileum
      - MRI small bowel study
      - capsule endoscopy
      - CT scan
      - perianal
        
        MRI pelvis
        
        examination under anaesthetic
    - - complications
        
        abscess
        
        fistula
        
        stricture
      - risk of colonic carcinoma
      - ~70% would need surgery within 20 yrs of diagnosis
        
        increased risk in smokers
        
        increased risk of redeveloping disease in joins
        
        50% will need further surgery within 10 yrs
    - - perianal
        
        abscess
        
        surgery to drain & repair
        
        antibiotics
        
        biologic therapy
        
        anti-TNF
      - methotrexate (immunomodulator for induction & maintenance of remission)
        
        used if
        
        patient dependant on steroids
        
        contraindicated
        
        teratogenic
      - surgery
        
        indicated for
        
        obstructive symptoms
        
        fistulae
        
        failure to thrive
  - - - erythema nodosum
    - - episcleritis
      - scleritis
      - uveitis
    - - primary sclerosing cholangitis
- - - - produces inflammatory enterotoxin & cytotoxin
        
        causes mucosal destruction
      - history of 4Cs antibiotics
        
        cephalosporin
        
        co-amoxiclav
        
        clindamycin
        
        ciprofloxacin
    - - food poisoning from chicken, contaminated milk etc.
      - commonest cause of travellers' diarrhoea (runoff into contaminated water)
    - - <5% have positive blood cultures
        
        20% have positive stool cultures at 20 wks
        
        prolonged positives associated with gallstones
      - lactose non-fermenters
    - - symptom onset usually within 48 hrs of exposure
        
        diarrhoea usually lasts <10 days
        
        post-infectious IBS common
      - contaminated food/water or touching contaminated animals/environment
      - tend to affect very young & elderly, immunocompromised & those on antacids
        
        invasive salmonella much more likely in those with HIV
    - - frequent bloody stools
        
        toxin can cause haemolytic-uraemic syndrome (HUS)
        
        haemolytic uraemia
        
        supportive treatment, antibiotics not indicated
        
        renal failure
        
        thrombocytopaenia
        
        more common in children/elderly
      - Shiga toxin gets into blood
    - - Shigella sonnei in children's nurseries
      - produces Shiga toxin
    - - reheated rice
    - - undercooked food/cooked food left out
    - - particularly common in autumn/winter
      - rotavirus
        
        children under 5 yrs
      - norovirus
        
        outbreaks in institutions
      - adenovirus
  - - - metronidazole
      - oral vancomycin
      - fidaxomicin
      - stop anti-diarrhoeals
- - - - squamous cell carcinoma
      - adenocarcinoma